The best hope for achieving significant savings in medical costs is through the elimination of unnecessary or duplicative procedures, which waste hundreds of billions of dollars a year. Government attempts to set boundaries inevitably run into cries of “death panels” and rationing, along with prideful reactions from many doctors, who assert the right to test patients as they see fit. But so many factors complicate that decision — from patients’ demands to doctors’ financial interests and fear of lawsuits — that a system without limits is untenable. It’s also unhealthy, in the sense that some patients are exposed to unnecessary risks.
That’s why it’s welcome that the medical profession — encompassing the people best qualified to set guidelines — is starting to take responsibility. Nine medical specialty groups, including the American College of Cardiology and the American Board of Internal Medicine Foundation, recently released a list of 45 tests and procedures that patients usually don’t need. Other medical specialty groups must follow suit, and even then those who’ve already weighed in should dig deeper for workable best-practice guidelines.
Then, last week, the Brookline-based Lown Cardiovascular Research Foundation went further, partnering with the New America Foundation on the first major conference to dedicated to “Avoiding Avoidable Care.” The 100 or so doctors in attendance addressed many of the steps necessary to reduce unnecessary treatments.
Defensive medicine was something attendees returned to time and again, and with some justification: A neurosurgeon, for example, has an 18 percent chance of being sued each year. Given that a malpractice suit can take five or six years to settle, the specter of litigation is always hanging over that discipline.
And yet, overall, defensive medicine amounts to only about $46 billion a year, or about eight days of annual national health care spending, according to Kennedy School economist Amitabh Chandra. That’s not small potatoes, he noted, but neither is it the biggest driver of unnecessary care.
So what are the larger reasons for over-testing and over-treatment? David Newman, an emergency physician and director of clinical research at Mt. Sinai School of Medicine, identified one as “scienciness,” which he described as doctors being very knowledgeable about the array of tests they could order but not the likelihood those tests will actually reveal anything of value.
Others said the way doctors are trained puts an emphasis on excessive testing and on acting rather than opting for a wait-and-see approach. “Medical school and graduate education are failing us,” lamented Dr. David Goodman, director of the Center for Health Policy Research at the Dartmouth Institute.
From the audience, David Himmelstein, a primary care physician and professor at City University of New York, brought up a topic that had, at least until that point, gotten short shrift. “Virtually everything we talk about as over-utilized is a reflection of a procedure that makes some corporate entity a great deal of money,” Himmelstein said. Why? Well, cardiologists, for example, can make substantial sums by interpreting the imaging work they order, and even bigger amounts if their practice owns the expensive imaging equipment. Himmelstein’s observation hung a little uncomfortably in the air.
It was left to Don Berwick, former administrator of the Centers for Medicare and Medicaid Services, to frame the challenge and the consequences the medical profession faces. Noting that some $11 trillion will be spent on unnecessary care over nine years, Berwick said that for universal health care to work, waste simply must be wrung from the system.
“We need the profession to rise to this,” said Berwick. “It is only the people who give the care who can change the way is delivered.”
He’s certainly right about that. If patients are to trust that cost-conscious health-care decisions are in their best interests, the change has to start with, and be explained by, their physicians. That’s why, despite the enormous challenge, it was heartening first step to see a roomful of medical professionals grappling with over-testing and over-treatment in a serious way.