By Brian L. Grant MD
Atul Gawande, MD once again hits a bull’s eye in this incisive New Yorker article on the massive problem and challenge of unnecessary “no-value” care.
In truth, “no value” is generous, since care with no value removes value from the system by diverting resources from the economy that could be creating value, and by increasing morbidity and occasional mortality that is inherently part of health care but is accepted as part of the risk benefit calculation.
When there is no benefit, one only encounters risk. Gawande cites a 2010 Institute of Medicine Report that 30% of health care spending, or 750 billion per year in the US, is wasted. Spread across the population of patients, this would mean that 30% of the care received offers no value (while carrying risk), and 30% of the care provided by hospitals, doctors, pharmaceutical manufacturers, physical therapists and so on, are wasted. Of course, human nature being what it is, the average patient likely thinks that it is someone else receiving such wasted care and the average health professional may believe, or at least profess publicly, that all which they do or prescribe on behalf of patients is necessary and appropriate.
If we were to accept this 30% statistic and were somehow able to curtail waste without shifting or increasing costs we would not be in the crisis of cost that we find ourselves in. Our 18% or so of GDP spent on health care would be a more moderate, but a still substantial, 12%. By any reasonable standard, Gawande is describing a situation that ought to outrage every citizen. How much of our many other crises could be abated if 750 billion dollars were allocated to them? Education, poverty, social justice, homelessness, child abuse, and neglect? Or for those with more libertarian views, if this money were redistributed to the 319 million Americans for their own spending, we would each by richer by $2,351.00 per year! What would such wealth unleashed on the economy accomplish?
Why does this problem exist? I believe it is a combination of factors including ignorance, greed, and indifference. The ignorance is preventable but is largely driven by the indifference of a consuming population who have little economic motivation to be mindful of what they receive since others are paying the costs via private and public insurance. Greed speaks for itself and takes the form of deliberately doing the unnecessary or a deliberate denial of the potential that a particular intervention is not needed by ignoring the evidence or not asking the right questions. The patient population in the presence of motivation is capable of making informed decisions by asking tough questions of their physicians and doing their own research.
Fortunately, as the article describes, there are systemic alternatives that can lead to change in this pattern of behavior when one is willing to acknowledge and confront the problem.