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Medical Expert Says U.S. Health Industry Often Guilty of “Overkill”

May 21, 2015 (8 min read)

Significant percentage of medical care procedures is unnecessary

Much has been written about the explosion of health care costs in the workers’ compensation system. Indeed, most experts agree that medical care expenses now represent more than 60 cents out of every benefit dollar provided to injured workers [Harris Williams & Co., “Workers’ Compensation Overview,” November 2013]. To the extent that the delivery of medical care within the workers’ compensation setting mirrors the care provided generally to patients in the United States, an alarming amount of it is wholly unnecessary. At least, that is the implication of a recent article by Atul Gawande, MD, published in The New Yorker [“Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?”, The New Yorker, May 11, 2015].

Gawande, a general surgeon with a specialty in tumors of the thyroid and other endocrine glands, cogently points to a 2010 report from the Institute of Medicine (“the Institute”) that suggests that more than 30 percent of health-care spending—some $750 billion annually—does nothing to make anyone better. As Gawande notes, that’s more than our nation spends each year for K–12 education. High prices, administrative expenses, and fraud account for half the waste, says the Institute. An even bigger problem relates to the other half—the amount annually spent on unnecessary health-care services.

Gawande’s “Crude Check”

To test the Institute’s hypothesis, Gawande decided to do a “crude check.” On one particular afternoon, he had seen eight new patients whose records were sufficiently complete that he could review their past medical history in detail. Following that review, he concluded that seven out of eight had received unnecessary care. For example, two patients had undergone diagnostic tests that provided no real value, but which were costly. In another patient’s case, a physician had ordered an MRI, when she had already undergone an ultrasound and biopsy of a “suspicious” lump in her throat; according to Gawande, the MRI was not nearly so accurate in detecting thyroid cancer as the ultrasound she had already received. Gawande noted that still another patient received genetic testing that was not relevant to her condition or proposed treatment.

Doing “Too Little” versus “Too Much”

Gawande says one of the primary forces behind the surge in unnecessary treatment comes from doctors themselves. He allows that, as a physician, he is “far more concerned about doing too little than doing too much.” He adds that it’s the scan, the test, the operation, that he should have done—but did not—that sticks with him, haunting his memory for years, not the extra test he has occasionally ordered. He posits, however, that the “extra” tests are costly, particularly in the aggregate.

Information Asymmetry

Gawande carefully notes that even the most reputable professionals err toward overkill. If you hurt your knee and see an orthopedic surgeon, you’re likely to hear that surgery might be required. See a physical therapist and you get a different answer. From our legal world, it’s like asking a lawyer if you need a new will. The difficulty, says Dr. Gawande, is often driven by a phenomenon first described first by Kenneth Arrow, Nobel Laureate in Economics (1963): information asymmetry, the “severe disadvantages that buyers have when they know less about a good than does the seller.” According to Gawande:

Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.

According to Dr. Gawande, the numbers are staggering. Each year in the United States, its 300 million people undergo 15 million nuclear medicine scans, 100 million CT and MRI scans, and 10 billion laboratory tests. Sometimes they are absolutely necessary. Often they are not.

Asymmetry Particularly Problematic in the Comp Arena

Workers’ compensation practitioners know that the information asymmetry can be particularly acute when it comes to workers with limited education or those for whom English is not their native language. A recent Missouri case illustrates this point. In Gonzales v. Butterball, L.L.C., 2015 Mo. App. LEXIS 139 (Feb. 11, 2015), the worker was a U.S. citizen. His native language, however, was Spanish and he could neither read nor write English. He complained of chest pain after picking up a turkey weighing some 80 pounds. Because he could not communicate effectively with medical staff at the company clinic, his complaints were regarded as a cardiac event, rather than minor muscle strain. He underwent an EKG, a CPK, and other testing at a local hospital and was eventually transferred to a major medical center where the worker underwent a cardiac catheterization that showed he had normal coronary articles with normal LV function. The worker returned to work without any lost time, but the employer was left with a $20,000 medical bill.

Overtesting Creates New Problem: Overdiagnosis

Gawande cautions that all the unnecessary testing produces another, expensive problem: overdiagnosis. Gawande is careful to say that he isn’t speaking of “misdiagnosis” (like that seen in the Gonzales case), but rather the correct diagnosis of a disease or condition that isn’t going to bother the patient in his or her lifetime.

He catalogs the case of one of his patients, Mrs. E., a woman in her 50s who had a thyroid lump, which was found to be benign. However, the pathologist discovered a pinpoint “microcarcinoma”. Gawande adds that when the original surgeon told Mrs. E. that a cancer had been found in her thyroid, “which was not exactly wrong, she believed he’d saved her life, which was not exactly right.” According to Gawande, a thyroid expert, more than a third of the population has these tiny cancers in their thyroid, but fewer than one in a 100,000 people die from thyroid cancer a year. He says it’s only the rare microcarcinoma that develops the capacity to behave like a dangerous, invasive cancer.

Rabbits, Turtles, and Birds

Gawande cited another medical scholar, H. Gilbert Welch, a Dartmouth Medical School professor, who has written a new book, Less Medicine, More Health [Beacon Press, ISBN 978–0–8070–7164–9].  According to Gawande, Welch describes the situation this way:

[W]e’ve assumed … that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.

Gawande adds:

We now have a vast and costly health-care industry devoted to finding and responding to turtles. Our ever more sensitive technologies turn up more and more abnormalities—cancers, clogged arteries, damaged-looking knees and backs—that aren’t actually causing problems and never will. And then we doctors try to fix them, even though the result is often more harm than good.

Gawande said that the patient, Mrs. E., “had a turtle.” How do you tell her that she should just have it periodically monitored? She has cancer!

Collision Between Evidence-Based Medicine and Clinically Based Medicine

Concerning Mrs. E.’s condition, Gawande indicates that expert guidelines recommend no further treatment when these microcarcinoma are found. The doctor does not discuss, but indirectly points to an active debate within the workers’ compensation community: when and whether evidence-based medicine should trump clinically-based medicine. Gawande does discuss the strides made in the 1990s in reducing the number of unnecessary procedures that came about when the insurance industry began to police the situation. He called it the “Mother, may I?” period. Alas, having decisions made by bureaucrats resulted in a backlash. The insurers backed off and the cost of medical care skyrocketed.

The debate within the comp world is active and it’s loud. “How dare the employer or insurer tout a study that shows a course of treatment isn’t effective; my physician says it might work.” How dare a researcher armed with data related to 10,000 injured workers trump one’s treating physician? “She’s seen several patients a lot like me.”

Reward For Quality, Not Quantity

In  his earlier piece, “The Cost Conundrum” [The New Yorker, June 1, 2009 issue], Gawande had compared Medicare costs in two Texas towns: McAllen and El Paso. They had the same demographics, but El Paso spent just half of what McAllen spent for Medicare.  What was worse: El Paso seemed to have better results.  According to Gawande, McAllen’s doctors were ordering more tests.  They admitted more patients to the hospital.  They performed more procedures in almost every category than their colleagues in El Paso. Gawande described McAllen as a “profit-maximizing medical culture”:

Specialists not only made money from the services they provided; many also owned stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital, which brought them even bigger returns from health-care overuse.

Indeed, Gawande says medical costs have always risen when physicians and other health care providers are paid for the quantity of their service, rather than the quality. “The system gives ample reward for overtreatment and no reward for eliminating it,” says the doctor.

Physician reaction to the 2009 article was hugely negative, but the spotlight shined on the area caused change. One doctor there told Gawande, “We took a wrong turn when doctors stopped being doctors and became businessmen.”

No Quick Fixes

Gawande doesn’t point to quick fixes. Some of his suggestions are limited to Medicare. But still, his points are well spoken and suggestive. His emphasis on quality care, rather than the quantity of care is particularly important. Such an emphasis could reap dividends within the workers’ compensation community. With the rise in prevalence of co-morbid conditions, such as diabetes, high blood pressure and obesity, Gawande’s suggestions could not only slow the growth in the medical care portion of claims, they could lead to improved quality of life for many workers.

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