By Dr. David Downs
Medical science has advanced at a remarkable pace. We can now replace worn joints and diseased heart valves, open clogged arteries and identify cancers before they become untreatable. We can see into the center of the body with remarkable detail using CT scanners, MRI machines and other technologies — all without pain or discomfort.
These and many other modern medical miracles are generally viewed as a great benefit to the health of those for whom they are available. And in the American spirit of newer, better and faster, we have taken to these services avidly. It is one reason we spend more money on health care in the United States than any other country – by a lot!
But questions have arisen as to whether more and newer is always better treatment. Researchers have looked carefully at use of new and old high-tech medical care across the United States, and have identified wide variations in the degree to which it is provided from one region to another.
You would think that in areas of the country where high-tech services are provided to more people, that health would be better than in areas where they are provided less frequently. Surprisingly, that is not the case. In fact, areas that use more high-end medical technology often have worse health outcomes. How can this be?
Let’s look at a common procedure; it is highly likely that you know someone who has had it done or that you have had it done yourself. It is called coronary angioplasty and involves inserting a tiny balloon into an artery supplying blood to the heart muscle that has become narrowed.
By inflating the balloon, the narrowing can be lessened and a small metal tube called a stent can be inserted to keep the narrowing from coming back. If you are in the middle of a heart attack, this procedure can save heart muscle and your life.
But what if you have a narrowed artery causing chest discomfort when you exert yourself that is not immediately threatening to cause a heart attack (stable angina)? Opening the artery can relieve your symptoms, but will it keep you from having a heart attack down the line? Can it help you to live longer? Does it help relieve symptoms better than medications?
These are important questions if you are considering an invasive procedure that is generally safe but can occasionally result in a stroke, heart attack or even death. And the answers are surprising. People who have coronary angioplasty for an isolated narrowing of a coronary artery do not have fewer heart attacks than those who don’t have the procedure. They do not live longer and they do not avoid having to take medication (in some instances they may have to take more medication).
Even though we know angioplasties have little net benefit for many people who have coronary artery disease, they are still done frequently and those who get them usually believe they will prevent heart attacks and death (88 percent and 76 percent respectively in one study). And these were people who were given “informed consent” by their cardiologist before the procedure.
The end result is a proliferation of very expensive, somewhat risky interventions that drive up insurance premiums and make health care less affordable, but produce very little if any improvement in health.
So what can be done to improve the decisions we make with our doctors about our treatments?
For many health problems, there is more than one option for treatment that is supported by medical evidence. In those cases, what people value, what their goals are, how healthy they are and a number of other individual factors should influence the decisions they make. But in order for those personal factors to become part of the decision, the person who is affected must understand all the alternatives for care and the risks and benefits each one carries. And the health care provider who makes the decision with them must understand their patients’ values, goals, needs and fears to be effective in jointly making choices about what care is right for each individual.
This process is referred to as shared decision-making.
There are many examples of what is called preference sensitive care – care for problems when more than one alternative is available and supported by medical evidence. In addition to angioplasty for stable angina, the list includes replacement of knees and hips, treatments for breast and prostate cancer, treatment including surgery for spine problems and many others.
A growing body of evidence shows that current decision-making is frequently undertaken with an accurate medical diagnosis, but a misdiagnosis of patient preferences for care. It is likely that some care is given to people who wouldn’t want it if they understood all the facts.
A recently published study in which patients were given detailed, unbiased and complete information about treatment for hip and knee arthritis chose to have hip replacements 28 percent less frequently and knee replacements 38 percent less frequently.
In another study, similar unbiased information was provided to patients with a herniated spinal disc and the number choosing surgery dropped by 30 percent. Not only were patients spared unwanted surgery through this shared decision-making process, many dollars were saved that could then go to pay for needed care.
In Colorado, a new approach to address patient needs and make care more affordable is underway using a smarter approach to insurance benefits. Called Engaged Benefit Design, it changes insurance in three important ways:
- Patient cost in the form of co-payments for many kinds of care that are high in value like prevention, good care for chronic diseases like diabetes and others is eliminated so that care is easier to get.
- Selected forms of preference sensitive care (as described above) cost a little more in the form of higher co-payments to alert consumers there are alternatives and it is worth learning more before making a decision.
- Patient decision aids – tools that provide unbiased, complete, accurate and understandable information about choices – are provided.
In this way, insurance benefits can be redesigned to produce smarter consumers making better decisions about their own care.
Better-engaged patients make choices that lead to better care, frequently at lower cost.
See engagedbenefitdesign.org for more information.
David Downs, M.D., is a physician in internal medicine, practicing at Kaiser Permanente in Denver. He also is medical director of Engaged Public, a nonprofit public policy organization working to build public understanding and participation on a wide variety of issues. He is past president of the Colorado Medical Society and a member of the Solutions advisory committee.