October 27, 2011

Part 2: Even With Good Info and the Best of Intentions, Doctors, Patients, and Families Will Still Opt for Useless -- Maybe Harmful -- Tests and Procedures

If patients become better informed and play more active roles with their doctors to manage their health care, some reduction in overtreatment might result, but it wouldn't have a major impact because of the way doctors, patients, and family members interact in today's health care system.

Role of Doctors
In a recent survey reported in the Archives of Internal Medicine, nearly half of the more than 600 primary care doctors who responded believed that their patients received too much care. Almost a third of them acknowledged that they were partly responsible for this surfeit of care.

The doctors surveyed attributed the pressure to overtreat patients primarily to three factors:
  • Almost half believed that inadequate time allotted to patients led doctors to order more tests or refer them to specialists.
  • More than three quarters believed that the fear of malpractice suits or of being perceived as not doing enough put undue pressure on them to order more treatment.
  • More than half believed that the quality measures and clinical guidelines endorsed by health care experts and insurers as a way of reining in health care costs were in fact having the opposite effect. Ironically, most of these guidelines -- which insurers increasing link to reimbursement -- are based on more testing and treatments.
  • Some accuse doctors of prescribing unnecessary care for financial gain. But only 4 percent of the doctors surveyed believed that was a factor. (A brave 4%!)
In an editorial accompanying the study, Dr. Calvin Chou, professor of medicine at the University of California-San Francisco, says overtreatment of patients results not from a desire for personal gain, but from a sense of overwhelming helplessness: "Many doctors feel like they are on a treadmill and are running scared because of malpractice and having to check off all the checkboxes of quality measures. They feel like they are in an oppresive situation that they can't do anything about."

Experts point to several reasons for the persistence of overscreening  and overtreatment:
  • habit
  • incentives that pay doctors and hospitals for individual procedures
  • quality assessments that rely on how many patients receive such tests
  • physicians' fear of upsetting elderly patients  -- or their children -- by suggesting that screening is unnecessary because a patient is too old or too sick to benefit
Today, when discussions about end-of-life care are branded as "death panels" and curtailing unnecessary tests and procedures is regarded as "rationing health care," it's not surprising that overtesting and overtreatment occur. Many doctors conclude it's easier simply to order a test than it is to discuss its risks and benefits with patients.
The Patient
In a recent news story from Los Angeles, family physician Pamela Davis recounted what happened when she advised her robust 86-year-old mother to stop getting mammograms and routine colon tests. Her mother was incensed, accusing her of wanting to "save money to spend on the young people and just let us old folks die." After the article was published, Davis received a wave of hate mail -- some of it from doctors -- making similar accusations.

Screening has become a mantra, trumpeted by advocacy groups. The message to patients is "you're a good person if you get screened," says Dartmouth physician Lisa Schwartz. The message for older patients, regardless of their health, Schwartz continues, should be: "It's not always in your best interest to do more or to keep looking. But we never seem to talk about the downside of testing."

Much of today's health care is provided by specialists. Patients either go to them directly or are referred to them by primary care doctors. The typical patient does not react well if the specialist tells her that she really doesn't require any further treatment or screening.

In some cases, doctors do recommend against testing, but patients demand it. In a recent Washington Post article about seniors' reluctance to forgo traditional screenings, internist Alan Pocinki said he tried to dissuade an 80-year-old man -- a survivor of several heart attacks -- from additional PSA testing. The man's son, a Boston oncologist, agreed. But the elderly patient insisted. The PSA test found an elevated reading, which led to a biopsy, which indicated cancer. Unfortunately, the procedure resulted in the man's contracting a serious infection. Not surprisingly, he wishes he'd never been tested.

Robert Smith, director of screening at the American Cancer Society, says he suspects doctors often continue screening terminally ill patients to avoid difficult conversations (such as "You won't live long enough to benefit from whatever we may find").

Family Members
Family members often get involved in decisions about screening and treatment at the end of the patient's life, when the largest health care costs occur. In 2009, Medicare paid $55 billion for doctor and hospital costs for care during the final two months of patients' lives. This is also the time when family members step in and demand that everything possible be done to save their loved one. Doctors can understandably feel uncomfortable telling family members the sad, unfortunate truth: nothing else will help your loved one's terminal condition.

For years now, researches have pointed to excessive care as an important factor behind spiraling health care costs. Some studies estimate that up to 30 percent of care delivered in the U.S. is unnecessary and sometimes even harmful. More and more policy makers and insurers have been urging action to address that waste.

But what? As patients, we can all become better informed and take more pro-active roles in test and procedure decisions (part one of this discussion). But, given the problem's dimensions, and the combined tendencies of doctors, patients, and families to choose "more," not "less," the efforts by informed individuals can't make much difference.

It seems to me there's only one solution: Medicare and private insurers begin denying reimbursement for tests and procedures that cannot improve the patient's quality of life, and may even cause harm. But, as we've seen in the firestorms created by proposals to rein in PSA and mammograms, this action would touch the third-rail in our political system -- cutting back current entitlements.

What do you think? What can we do? Is there another solution? Please, share your thoughts!

1 comment:

Kathy said...

Kathleen wrote: "John, this
exactly what the insurance companies are trying do and are being pilloried for.
But they aren't always wrong or unfair. Just because there is an MRI facility
nearby - perhaps owned in part by your doctor - doesn't mean, for example, that
you need an MRI for what might be just a routine rotator cuff problem. And if
you ask a podiatrist who happens to own an X-ray machine to remove a difficult
splinter from your feet, you don't really need X-rays of both feet. The
guidelines of physicians' associations re when certain costly screening
procedures are warranted make good sense. (Note that they are the ones who are
urging fecal occult blood tests, mammograms, sigmoidoscopies, and periodic
colonoscopies on us as screening tools.) A good litmus test: If I had to pay
for this out of my own pocket, would I still consider it necessary for
diagnosis and treatment?"