Too Much of a Bad Thing

I've just recently caught up with a 2007 book by journalist Shannon Brownlee, Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer. Although some of the specific policies she cites are being changed by the Affordable Care Act, her basic argument is worthy of our attention.

Most advocates of single payer health insurance are justifiably concerned about undertreatment, as represented by the 45,000 Americans who die every year from lack of adequate health care, but overtreatment is part of the problem because it drives up costs and convinces people that we can't afford health care for all. Overtreatment accounts for one-third to one-fifth of all health care spending, which amounts to $500-$700 billion in waste per year. In effect, the poor get too little health care because the rest of us get too much.

Overtreatment also leads to deaths and illnesses caused by too much medical care. The book is filled with these horror stories. In fact, almost anything that puts us in that house of confusion we call a hospital increases our risk of becoming a victim of medical error. Brownlee places the death toll for unnecessary care at 30,000 per year. (Unfortunately, although Brownlee includes footnotes, the sources of some of her statistics, including those in this and the preceding paragraph, are not cited.)

Overtreatment comes in several varieties. Unnecessary surgery is a huge problem, since it usually costs $50,00-$100,000 per operation. Heart and back surgery are the worst offenders. Researchers at Dartmouth first documented overtreatment when they noticed large regional and hospital differences in surgery rates that were not explained by illness rates in the area. Unnecessary tests cost less per incident, but are much more frequent. A special problem brought on by too many imaging tests, from mammograms to CT scans, is that reading the results is prone to error and leads to the “discovery” of non-problems, resulting in further unnecessary procedures. Finally, there are two chapters on the pharmaceutical industry, its creation of “illness” (“restless leg syndrome,” anyone?), and its marketing of ineffective and sometimes harmful drugs. (The definitive work on this subject is Marcia Angell's The Truth About the Drug Companies [2005])

Brownlee suggests several reasons for overtreatment. The Medical Institute has estimated that only 4% of medical treatments (drugs, tests, surgical procedures, etc.) are backed by strong scientific evidence of their effectiveness. Another 50% are supported by weak evidence; the rest have no support at all. In this environment, there are huge opportunities for subjective judgments by doctors, who are under pressure from all sides to do something rather than wait and see.

Our largely fee-for-service payment system is another cause of overtreatment, since the more treatment they provide, the more the medical establishment gets paid. To make things worse, both Medicare and insurance companies overpay for some treatments, especially surgery, and underpay for others, such as emergency and psychiatric care. Hospitals allot major resources to these profit centers (“centers of excellence”), while closing emergency rooms and psychiatric wards in spite of unmet demand. Brownlee labels this system “supply-driven demand.” If a hospital has too many beds, the beds somehow miraculously get filled. When the hospital spends several million dollars on a new MRI, the doctors request many more scans. An oversupply of heart specialists leads to an excess of heart surgery. Drugs advertised on television get prescribed, and so forth.  Brownlee charitably suggests that this is a result of unconscious biases.

The solutions are fairly obvious. They will be costly to implement, but will pay off in the long run. First of all, research on the effectiveness of medical treatments is badly needed.  It must be conducted not by the manufacturers of drugs and medical devices, but by disinterested university-based researchers whose work is supported by the government. Secondly, organizations such as the Veteran's Administration and Kaiser-Permanente have been shown to reduce costs and improve treatment outcomes by coordinating patient care. This is accomplished in part by good computer tracking. It also requires assigning each patient to a general practioner who knows the patient well enough to recognize her in the grocery store. Brownlee strongly believes we need more generalists and fewer specialists. Finally, it requires a reimbursement system that rewards doctors for producing good patient outcomes, rather than paying them a piece-rate for each procedure.

Overtreated belongs on everyone's short shelf of books about health care policy.