Managed care became loathed in the 1990s. The recent recommendation to reduce breast cancer screening set off a firestorm. On a personal level, anyone who has made a decision about his or her own care knows the nagging worry that comes from not choosing the most aggressive treatment.Needless care? That's a curious phrase because someone whose options are "needless care" and nothing else will take the "needless care" if that gives the promise of a cure or improved health situation. Even where the options are "needless care" and other treatment choices, the patient may still take "needless care".
This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment. Consider that a recent study found that 15,000 people were projected to die eventually from the radiation they received from CT scans given in just a single year — and that there was “significant overuse” of such scans.
From an economic perspective, health reform will fail if we can’t sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare’s long-term budget deficit will grow.
So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. “Being able to say no,” Dr. Alan Garber of Stanford says, “is the heart of the issue.”
It’s easy to come up with arguments for why we need to do so. Above all, we don’t have a choice. Giving hospitals and drug makers a blank check will bankrupt Medicare. Slowing the cost growth, on the other hand, will free up resources for other uses, like education. Lower costs will also lift workers’ take-home pay.
But I suspect that these arguments won’t be persuasive. They have the faint ring of an insurer’s rationale for denying a claim. Compared with an anecdote about a cancer patient looking for hope, the economic arguments are soulless.
The better bet for the new reformers — starting with Donald Berwick, the physician who will run Medicare — is to channel American culture, not fight it. We want the best possible care, no matter what. Yet we often do not get it because the current system tends to deliver more care even when it means worse care.
It’s not just CT scans. Caesarean births have become more common, with little benefit to babies and significant burden to mothers. Men who would never have died from prostate cancer have been treated for it and left incontinent or impotent. Cardiac stenting and bypasses, with all their side effects, have become popular partly because people believe they reduce heart attacks. For many patients, the evidence suggests, that’s not true.
Advocates for less intensive medicine have been too timid about all this. They often come across as bean counters, while the try-anything crowd occupies the moral high ground. The reality, though, is that unnecessary care causes a lot of pain and even death. Dr. Berwick, who made his reputation campaigning against medical errors, is a promising (if much belated) selection for precisely this reason.
Can we solve the entire problem of rising health costs by getting rid of needless care? Probably not. But the money involved is not trivial, and it’s the obvious place to start.
It isn't a guarantee that a stent or bypass will prevent a heart attack, but it might. A whole lot of research has gone into this area, and doctors around the country still counsel their patients to go for the stents and bypass procedures. There are studies in support of stenting and there are those opposed in some cases. It depends on the situation, but
Giving patients more information is a win-win for all involved, but it might not necessarily mean that patients will choose the less-costly option. It simply means that more options will be provided to a patient that may already be bewildered by their situation and has to deal with the stress of a tough medical situation and decisions that affect their lives and those of loved ones.
It's far easier to claim a cost savings from pushing generic drugs where name-brand drugs are in use since they are equivalent medications, but that's a drop in the bucket compared to the whole range of medical procedures now in use.
C-sections are more common because they provide a measure of timeliness (you can schedule a C-section, but a natural birth can occur at any point), but also because doctors may shy away from a natural birth due to concerns over lawsuits and possible complications from childbirth that may render the child disabled in some fashion.
CT scans may be overused, but who's going to determine when they should or shouldn't be used to an even greater degree than they are at present. After all, under the current system, insurers already deny plenty of claims and opt to not reimburse for CT scans and other procedures, so how exactly will the new federal plans constrict and limit the procedures to only those that are necessary when there are already monetary incentives in place to restrict payment for those procedures. That's one of the complaints about insurers at present, and yet the cure for cost containment is even more of the same thing that people already complain about insurers - limiting treatment and diagnostic options.