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