The DO | Special Coverage | OMED 2013

Author: Overtreatment the ‘monster’ of wastefulness endemic to U.S. health care

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”We've replaced caring with doing,” says health policy expert Shannon Brownlee, shown here after her keynote presentation at OMED 2013 today. (Photo by Patrick Sinco)

In a New York hospital, physicians decided to place an unconscious, skeletally thin, terminally ill AIDS patient on a ventilator. Afflicted with severe dementia as well, he could not give informed consent and had no family member or friend who could act on his behalf. The patient developed pressure ulcers and died a few weeks later.

This incident is a typical example of the wasteful, harmful overtreatment of patients that plagues the American health care system, Shannon Brownlee stressed during her OMED keynote address today. “Dying in an ICU on a ventilator, unconscious, seems to me a terrible way to go and a monstrous waste of money to boot,” said Brownlee, the author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.

And patients who don’t have severe health problems often become sicker and have their lives shortened because of unnecessary medical interventions, Brownlee said.

With significant geographic variation, dependent on the proportion of particular medical specialists and the availability of particular medical equipment in a locale, patients in the U.S. commonly undergo excessive, aggressive medical treatments, Brownlee said. This greatly increases both patient mortality and the costs of delivering care.

Poorly coordinated, unnecessary tests and interventions often lead to debilitating or deadly infections, life-threatening side effects and complications, and avoidable emotional suffering, Brownlee said. The more time patients spend in a hospital, the greater the chance of errors or nosocomial infection occurring.

While Americans tend to be overtreated, they are also undertreated when it comes to basic preventive care, she said. The fee-for-service payment model rewards physicians for the volume of procedures they perform rather than the quality of care.

A longtime health care journalist who wrote extensively about technological breakthroughs, Brownlee became aware of the health system’s excesses in part through personal experiences. Twenty years ago, her father was prescribed a statin drug for high cholesterol—his only risk factor for heart disease. The drug nearly destroyed his kidneys.

Shannon Brownlee

“We’ve replaced talking to the patient, taking a careful history, with testing. We’ve replaced healing with technology.”

“I know what medicine is capable of,” Brownlee said, noting that her father survived due to extraordinary medical care. “But I also know it’s in terrible straits.”

Categories of waste

Brownlee pointed out that the waste endemic to the U.S. health system comes in many varieties, all of which cost billions of dollars a year. The problems include fraud and abuse; administrative waste, such as incompatible electronic health record systems; and discrepancies between physician fees and care-delivery costs.

But the other sources of waste are even worse because they cost not only money but also lives, she stressed.

“Lack of access and failure to receive needed care is one of the leading causes of death in this country,” said Brownlee, citing estimates that “undertreatment” kills an estimated 35,000 to 45,000 Americans a year. “I hope that when people enroll in the [health insurance] exchanges, that problem will be reduced.”

Failure to coordinate care is another category of waste the Affordable Care Act targets. But “the monster of them all” is overtreatment, according to Brownlee.

“[Overtreatment] is the most pernicious because it causes vast harm to patients while simultaneously crippling the nation financially.

“Conservative estimates put the amount of overuse last year at $210 billion. Other estimates put it closer to $700 billion to $900 billion.”

Brownlee noted that as many as 50% of medical tests and interventions are unwarranted, according to some estimates. “Imagine if half of what we do to patients is useless and potentially harmful. That’s shocking,” she said, noting that the most vulnerable to overtreatment are the very young and the very old.

“We’ve replaced caring with doing,” she said. “We’ve replaced talking to the patient, taking a careful history, with testing. We’ve replaced healing with technology.”

Better health system

Brownlee described the improved health care system she envisions, which she believes the Affordable Care Act will help bring to fruition.

“For one thing, a hospital would no longer be considered a cathedral of health,” she said. “More and more care would be delivered in our homes and our communities.”

The U.S. health system of the future will emphasize primary care rather than specialist-driven, hospital-based care, said Brownlee, who is the senior vice president of the Lown Institute in Brookline, Mass., which advocates humane, rational, cost-effective medical care.

The health care workforce is going to change, she told OMED attendees. “More care will be delivered by people who are not physicians—home health aides, nurses, physical therapists, physician assistants. All will have an expanded role as care moves away from the hospital and into the community.”

Physicians have reason to embrace health care transformation, Brownlee stressed. “The work you do will change for the better,” she said. “You will spend more time with the sickest, the frailest and the most vulnerable. You will spend less time filling out paperwork for billing.

“And you will feel appreciated by your patients and supported by your colleagues and society.”

2 Responses

  1. Todd Fredricks, DO on Oct. 12, 2013, 5:58 a.m.

    While Brownlee has some nice points such as the health care workforce will change she is completely wrong in the assertion that under transformation our work will change for the better. She has obviously never worked for the VA.

    When I worked for the VA I found the essence of medical bureaucracy. Primary Care doctors who can only see 10-15 patients a day because of the insane amount of reporting and required elements in their encounters created a documentation nightmare. She is delusional if she thinks that regulator and bureaucrats who are far divorced from the patient encounter won’t demand an ever increasing amount of metrics by which to “assess” the level of quality and care and they will require the provider to document that data taking more time away from patients.

    Additionally, no mention of tort reform is made. Until that is dealt with you will continue to see defensive medicine practiced and deltas like that between Ohio FPs paying $20K a year without OB and Idaho FPs paying $6K a year. The PPACA made no impact on that because the reality is that the lawyers who wrote that are not going to cut their colleagues throats.

    She seems to be historically ignorant of what medicine used to be in the United States. 50 years ago we had a system where care was physician office centered, affordable and responsive to patient needs. Physicians cared for the sickest patients and the worried well had family structures that kept them from seeking unnecessary medical care that could be delivered via self care. She fails to understand essential cultural issues as well. I would direct her to such things as smoking which was not outlawed under the PPACA and is perhaps the single greatest cause of preventable illness in the United States.

    She might have chosen to examine the observations of Sonia Shah in address the issues with malaria although they are applicable to any socially difficult health issue.


    And finally as is the wonkish thing to do we fail to study those places that find a way to deliver very high quality care for very low prices to which I would point her to the work of the Heart Institute of the Caribbean

    Scale is a huge problem that we have ignored in medicine. The simple question of why do our poorest people own iPhones with more computing power than the entire Saturn V system that took us to the moon, but we have failed to see such costs drop in health care. Her concept of massive regulatory schemas to do the same for medicine is ignorant of basic economics and past government track records with large programs. Apple does what it does because it is sensitive to actual wants in the market and seeks the most efficient method to deliver it even before people know that they want it. the PPACA is 2600 pages of law with about 8000 pages of regulatory guidance and growing.

    Does she really think that large contributors such as the major hospital groups are going to be left out in the cold with new regulation? Seriously? Does she not understand how politicians fuel their singular objective, reelection?

    We need a real dose of reality and all she has done here is remind us that we are about to be taken for a huge ride in spite of massive historical and performance record that suggests that trying to one size a solution for 310 million people won’t work for us any more than it worked for the Soviet Union with only 200 million people.

    We have met the enemy and he is us…

  2. Jon Schriner D.O. on Oct. 12, 2013, 8:03 a.m.

    She is right on for the most part. But it is complicated by the legal system and the Hospitals drive to keep money flowing into that institution. ACO’s and ACA will not solve this but add just another layer of bandages to the system. Making patients more accountable for the cost will drive a more cost effective system. Insurance has divorced the patient from knowledge of the costs. Until patients realize true costs and accept their responsibility for it like that of all other countries in this world we are just plowing the same fields. No other country acts like we demand of our “medicine”. No other country in the world has the Legal force driving defensive medicine. I for one have been to many “foreign” countries and teach many Foreign Physicians, and observed their system of care deliverance. While not perfect, it does contain costs. In the USA we have been “spoiled” and until we come to grips with that don’t expect change.

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