By Diane Carman
Just say no.
Thats what the Colorado Medical Society and a growing number of other health care organizations nationwide want patients to start doing.
No to useless antibiotics. No to unnecessary scans. No to diagnostic tests at too-frequent intervals. The list goes on and on.
Its a baby step toward sanity in a health care system that some say has become an irrational market of questionable procedures, exorbitant costs and mediocre outcomes.
About one-third of the interventions we do are really unnecessary, said Dr. Jan Kief, who just finished her term as president of the Colorado Medical Society. That costs us over $750 billion a year.
The effort is part of the Choosing Wisely campaign created by the American Board of Internal Medicine Foundation. The Colorado Medical Society is the first state organization to endorse the effort.
In Choosing Wisely, physicians across the spectrum of medical specialties nationwide have created lists of procedures, tests and drug treatments that deserve second thoughts before doctors order them or patients accept them.
The lists, available online, are a catalog of familiar procedures that have been overused, misused or have been determined to be ineffective. Most patients and even many physicians are unaware of the latest research, so educating everyone is the goal of the Choosing Wisely campaign.
A lot of things we thought were good to do are on those lists, said Kief. Now the studies show the evidence is not there that they make a difference in outcomes with patients.
Further, she said, doctors no longer can ignore the cost factor.
A lot of patients have high-deductible insurance now, she said, and for those who dont have high deductibles or who have coverage under Medicare or Medicaid, controlling costs is still important. We have to be good stewards of the dollars being spent on health care in America.
Jay Want, chief medical officer for the Center for Improving Value in Health Care,said much of the problem is the result of the way physicians are compensated in the U.S. health care system.
Fee-for-service drives volume, he said, so instead of adhering to the accepted protocols and only ordering those procedures when specific indications are found, the indications tend to broaden.
Most people, for example, are told they should undergo a colonoscopy every 10 years after they turn 50. More frequent colonoscopies are recommended only for persons who may have specific indicators, such as a family history of colon cancer, pre-cancerous polyps or some other specific risk factors.
Doctors who may want to maximize their incomes by performing more procedures may decide to test more often even in the absence of those recognized risk factors.
In the case of mammography, the doctors say that patients often insist on yearly imaging despite evidence that in most cases its unnecessary, a waste of money, exposes patients to radiation and can increase the risk of invasive treatment of false positive results.
Still, doctors order the tests.
Because there is more of a financial reward to do more stuff than there is not to do stuff, we do more stuff, Want said. This is a general theme. With a lot of the overused tests and procedures, theres a low perceived risk at the time, doing them generates revenue and, the medical professionals say, What the heck. It could help.
Dr. Heather Burton, who practices internal medicine at Kaiser Permanente, calls it customer service medicine.
In general, I try to shoot straight, she said. The longer I practice, the less I do customer service medicine.
For too many years, she said, everyone who arrived in a doctors office complaining of back pain had an MRI or a CT scan, despite research demonstrating that it was unnecessary and did not make any difference in terms of treatment of the condition or the outcomes of those treatments.
An examination and patient history tells us whats going on, she said. For most people, the results of a scan dont play a role in diagnosis or treatment.
Studies indicate that 30 to 40 percent of imaging scans are unnecessary, Burton said. Theyre very expensive and given the radiation exposure, I know were causing cancers.
I tell my patients that I want to protect them from the unnecessary radiation, expense and incidental findings that may have no bearing on their health but may cause them to worry or even seek treatment that could be harmful.
For example, Burton said that CT scans often reveal nodules on a patients thyroid gland.
Two-thirds of us have a nodule on our thyroid. Theyre more common than not having them, she said. But once a patient knows its there, its common to undergo a biopsy and have a lot of fear thats very unnecessary.
High deductibles change the equation
The Choosing Wisely campaign seeks to educate patients primarily to improve their care, but at the same time it provides valuable information for those who want to make cost-effective decisions.
Want said the high-deductible plans have shown that when the patient is spending his own money, he becomes more discriminating.
The system, he said, really needs a mild to moderate form of de-insurancing to create a more rational marketplace by making patients sensitive to the cost for unnecessary procedures and treatments.
That way, when they have a choice between a $1,000 colonoscopy and an identical one that costs $500, the chances are good theyll pick the lower-cost procedure.
If they arent paying the difference in cost, its irrelevant to them.
People with a $20 co-pay are not exactly shopping for good value in the health care market, Want said.
He emphasized, however, that such changes in how patients pay for health care would have to be proportionate to income to ensure access for low-income individuals.
At the same time, physicians operating in the fee-for-service environment have every financial incentive to maximize revenues.
The fee-for-service system is so insidious, Want said. The whole ethical construct is as a physician, with a superior body of knowledge, I am supposed to be entrusted with the responsibility of providing the appropriate care for the patient, respecting your values and your wishes. Im not going to worry about me at all.
In fact, in the fee-for-services system, we worry about me quite a lot. And as long as I dont hurt anybody, its OK.
He called the $2.7 trillion a year U.S. health care industry the biggest bonanza in unsupervised money in the history of the planet.
Its sucking up 17 percent of the GDP.
Information is power
In a speech to the IMA Foundation Leadership Forum in Denver Sept. 4, journalist Steven Brill said the system is out of control.
The sellers have all the information and all the power. The buyers have no price information and even if they had it, they have no leverage to do anything about it.
While patients still may struggle to get information about the cost of procedures and to shop intelligently for smart bargains in health care, the Choosing Wisely campaign provides volumes to help them start to become more discriminating about what care they receive.
A key part of the campaign is to teach people when not to take antibiotics.
This is one of my areas of great passion, said Kaiser Permanentes Burton.
Patients arrive in doctors offices with severe colds, sinusitis and other viral upper respiratory infections and often request antibiotics despite longstanding research that they are useless in treating them, she said.
My patients know Im not going to give them antibiotics for these things, said Burton. Its being disingenuous for doctors to give patients antibiotics when they know they wont help them. And people can get very severe illnesses from antibiotics.
Further, Burton cited studies that show that patients are not more satisfied with their medical care when doctors placate them by prescribing unnecessary antibiotics.
When patients arrive in doctors offices with horrible colds and they need to work and take care of their children, what theyre really saying is help me. Sending them away with unnecessary antibiotics is not helping.
Burton said Americans spend $1 billion a year on useless antibiotics for upper respiratory infections. I feel very passionate about this and my patients know that.
A diagnostic test that is tremendously overused, she said, is the Pap test.
- Dialysis provides no benefit in early stage kidney disease or in most elderly patients with kidney failure.
- MRI or CT scans for headache sufferers in most cases offer no benefit over taking a thorough medical history.
- Testosterone treatment for erectile dysfunction rarely is helpful because the cause usually is related to other medical conditions.
- Proton pump inhibitors, such as Prilosec, should only be prescribed in cases of severe and persistent gastroesophageal reflux disease. More than 70 percent of people taking the drugs probably dont need them.
- Supportive care is preferable over continued treatment of many advanced cancers. Patients whose cancers have not responded to three different treatments are not likely to benefit from further treatment.
For decades, Burton said, women over 18 have been given Pap tests every year for the rest of their lives. Generally, women under 21 or over 65 dont need Pap tests and almost nobody needs one more often than every three years.
Similarly, Want said the prostate specific antigen or PSA test is overused and misused.
Its a terrible test, he said.
Scopes of the upper gastro-intestinal system also are overused on patients complaining of heartburn, Want said.
Its a distortion of the specialty. Talking to somebody is not that financially rewarding, while scoping them is tremendously financially rewarding, he said.
The biggest boondoggle of all may be high-tech imaging scans.
They fit all the criteria for overuse, Want said. Doctors figure they couldnt hurt, they might help, theyre non-invasive and theyre very expensive. So they sell like hotcakes.
Experimenting with cost containment
Beyond the voluntary efforts, such as the Choosing Wisely campaign, health care systems in some parts of the U.S. are attempting to manage costs more aggressively system-wide.
Health organizations in areas with small, mostly rural populations with high concentrations of low-income or older residents are leading the way in this effort, Want said. Among them are Albuquerque, N.M.; Humboldt County, Calif.; and the state of Maine.
For his part, journalist Steven Brill said the system as a whole wont change until people truly can see and understand whats happening. He prescribes more investigative journalism.
I actually believe deeply in the power of embarrassment, he said. When theres no transparency, theres no responsibility.
And transparency involves more than just lifting the veil on hospital charges and health care system billing practices.
We need to start with the transparent way policymakers have been bought off by the health care industry, he said. Ours is the only developed country in the world that leaves health care to the free market. The experiment hasnt worked.
The costs are strangling us, he said, and we really dont have anything to show for it.