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The Practice of Medicine

The Problem of Unnecessary, No-Value Care

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.

Dr. Oz to Respond to Criticism

Dr. Mehmet Oz will question the credibility of critics who sought to have him removed from his position at Columbia in a segment on his show on Thursday, a spokesman for the show said.

Why is this important, and why does MCNTalk care? Dr. Oz has noted on his Facebook page, “I bring the public information that will help them on their path to be their best selves. We provide multiple points of view, including mine which is offered without conflict of interest. That doesn’t sit well with certain agendas which distort the facts.”

But in the multi-billion dollar world of celebrity and supplement endorsement, is there such a thing as “without conflict of interest?” And, as we noted in 2013, “In medicine there is a continuum between hard science, that which can be objectively observed and tested, so-called ‘art,’ and unsubstantiated beliefs masquerading as science.”

There is certainly no harm in being a good person and given the nature of many illnesses, conveying warmth while the body heals itself may be more than enough. But promoting amulets, strange foods, and other hocus pocus presented by charlatans does a disservice to society. Oz appears to personally promote unproven products and their promoters in his show – conveying an irresponsible and unearned aura of legitimacy. It appears he has embraced celebrity at the expense of credibility and his millions of fans are none the wiser.

Dr. Oz’s Presence on Columbia Faculty Deemed "Unacceptable"

Dr. Mehmet Oz, celebrity doctor and host of “The Dr. Oz Show” since 2009 is no stranger to controversy. In 2014 he appeared before Congress where he admitted that weight loss products he’s endorsed “Don’t pass scientific muster.”

This week ten prominent national physicians, led by Dr. Henry Miller of Stanford University, sent a letter to Columbia University’s Faculties of Health Sciences and Medicine noting that:

“Dr. Oz is guilty of either outrageous conflicts of interest or flawed judgements about what constitutes appropriate medical treatments, or both…members of the public are being misled and endangered, which makes Dr. Oz’s presence on the faculty of a prestigious medical institution unacceptable.” (Text of the letter can be found here.)

A graduate of Harvard University and both the University of Pennsylvania’s School of Medicine and their Wharton School, Dr. Oz has been on the faculty of Columbia University since 2001, where he serves as professor at the Department of Surgery; he also directs the Cardiovascular Institute and Complementary Medicine Program at New York-Presbyterian Hospital.

The nine other doctors from across the country included Dr. Joel Tepper, a cancer researcher from the University of North Carolina School of Medicine, and Dr. Gilbert Ross of the American Council on Science and Health in New York City.

In a recent The New Yorker article subtitled “Is the most trusted doctor in America doing more harm than good?” Dr. Oz is quoted as saying:

“Medicine is a very religious experience…I have my religion and you have yours. It becomes difficult for us to agree on what we think works, since so much of it is in the eye of the beholder. Data is rarely clean….You find the arguments that support your data and it’s my fact versus your fact.”

 

Celebrating 60 Years of Polio Vaccinations!

Sunday April 12th marks 60 years since the polio vaccine, developed by Dr. Jonas Salk, was declared “safe, effective, and potent.” April 12th also marks 70th years since of the death of President Franklin D. Roosevelt, whose paralysis was generally believed to be caused by polio.

Prior to 1955 the dreaded disease afflicted 600,000 people around the world each year, including about 50,000 children in the U.S. There is still no known cure for the disease which could cause various degrees of paralysis and is sometimes fatal. The testing of the vaccine, known as the Francis Field Trial, was the largest medical experiment in history up at that point, involving more than 1.8 million children from Maine to California.

Polio was officially eradicated in the United States in 1979. However, worldwide there still remain occasional outbreaks. In fact, in 2014 the World Health Organization declared polio’s renewed spread a “world health emergency” and the civil in Syria has led to more than 90 cases reported in that country. There have also been at least 20 cases reported in Pakistan in 2015.

Given recent measles outbreaks in the U.S. — another preventable disease with an effective vaccination — a 2010 documentary on the polio vaccination is receiving extra attention these days. Carl Kurlander, CEO of the company which produced the film A Shot Felt ‘Round the World reports increased interest in the film from groups interested in promoting the importance of vaccination. The World Health Organization hopes to eradicate polio worldwide by 2018.

“There’s no technical reason why there should be cases anywhere in the world by the end of this year,” said Oliver Rosenbauer, communications officer for the World Health Organization’s Global Polio Eradication Initiative. “It’s a question of political will and societal will.”

$30 Billion and Counting

Since 2009 the American taxpayer, according to Kaiser Health News/NPR/Montana Public Radio, has spent about $30 billion on the installation of electronic records systems in hospitals and doctors’ offices. However, right now the ability of the systems to converse with one another — so that patient records can be tracked from one facility to another — is at about a 2 or 3 on a scale of zero to 10, according to Robert Wachter, a hospitalist at UC San Francisco, and to technology entrepreneur Jonathan Bush.

Wachter has authored the upcoming The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, on information technology in health care.

Up until now, he says, there has been a financial disincentive for doctors and hospitals to share information. For example, if a doctor doesn’t have a patient’s record immediately available, the doctor may order a test that has already been done – and can bill for that test. Keeping EMRs [electronic Medical Records] from talking to each other also makes it easier to keep patients from taking their medical records — and their business — to a competing doctor.

Karen DeSalvo, the federal government’s health IT coordinator, is now working on standards for how to share digital information. 2015 might just be the time to move medicine more into the digital age. Wachter notes that as about a dollar of every $6 in the U.S. economy is spent on health care, a new IT boom in that sector means there are billions of dollars to be made.

Transforming Medicine into an Information Science

Responding to data trends is not a new to the practice of medicine. A quick Google search reminds us that the scientific method itself is defined as “principles and procedures for the systematic pursuit of knowledge involving the recognition and formulation of a problem, the collection of data through observation and experiment, and the formulation and testing of hypotheses.”

But the Icahn School of Medicine at Mount Sinai, New York — along with several other major medical schools — is pushing the concept further. They’re turning directly to data science as a big part of the future of medicine and health care.

Mt. Sinai has recently added Jeffrey Hammbacher to their faculty. Hammerbacher is a number cruncher — a Harvard math major who went from a job as a Wall Street quant to a key role at Facebook to a founder of a successful data start-up. He was recruited by Eric Schadt, a computational biologist at Mt. Sinai who had concluded that medicine was ripe for a data-driven revolution.

Hammbacher leads a team whose objective is to alter how doctors treat patients someday. For example, Mount Sinai medical researchers have done promising work on personalized cancer treatments. It involves the genetic sequencing of a patient’s healthy cells and cancer tumor. Once the misbehaving gene cluster is identified and analyzed, it is targeted with tailored therapies, drugs or vaccines that stimulate the body’s defenses.

Mr. Hammerbacher’s team does not do the basic science. Other researchers do that. His group works on the “computational pipeline,” he said, with the goal of making personalized cancer treatments more automated and thus more affordable and practical. “It’s ultimately what cancer cures are going to look like,” he said. Read more…

One Procedure, Many Prices

A new report from Blue Cross Blue Shield, The Health of America analyzed the cost of hip and knee surgeries in 64 areas across the US and found that the amount charged for the same procedure in the same city varied by as much as 313%.

The amount charged by the hospital is different from the amount negotiated by an insurer, which is itself different from the amount owed by a patient. That’s one reason deciphering hospital bills can be complex. It’s also a perfect example of why people can end up buried under a mountain of confusing medical debt if they are uninsured, lack good insurance, or simply don’t understand what their insurance plans actually cover.

“If you are in a plan that charges a $30 copay to see an orthopedist, that is your cost,” explained Dan Mendelson, the CEO of consulting firm Avalere Health and a former associate director for health at the federal Office of Management and Budget. But if you have a high deductible, if your surgery isn’t covered, or if you are uninsured, your already high costs may end up being three times higher just because you chose the wrong hospital.

Would these differentials in price exist if the patients had some skin in the game and they rather than their carriers were paying the bulk of the charge? Or if “skin in the game” meant more than meeting an annual deductible.  Though higher deductibles and co-pays do prompt patients and families to track expenditures and self-ration when possible, it’s not a step in the direction of making prices readily available or easy to understand.  And the disparities begs the question of why carriers like the Blues are willing to pay the higher prices when one of their insureds choose one of those hospitals.

Chronic Fatigue Syndrome Becomes Systemic Exertion Intolerance Disease

We have now seen another example of the medicalization of distress and the emergence of a new “disease” (as opposed to a group of symptoms) according to the linked article.

While we have not yet read the report and reserve full conclusions, the release suggests nothing new in terms of science, etiologic agents, or new findings that lend meaningful clarity and a path to recovery from the symptoms of Chronic Fatigue Syndrome (CFS). Rather, the deciding panel appears to have largely achieved a political goal of validating a syndrome of various symptoms that do not lean to any conclusions as to cause or cure. That those who claim to have CFS or whatever new name may be ascribed to it are suffering is not in question. What remains unknown is why, and whether this syndrome is caused by a lesion of some sort, a viral or bacterial pathogen. What is going on with this action?

Likely a number of things. One is that it addresses the anxiety and perceived stigma that often applies to experiences that are ill-defined and may be considered to have an emotional component, implying lack of validity for the sufferers. Noteworthy is that the panel is seeking responsive treatment and diagnostic codes. By validating a syndrome as a disease, the conversation changes to one of obligations and rights for the sufferers that they believe they lacked before.

And it implies and may create duties by others in the industry of treating diseases, including insurance carriers, employers, courts and the culture to increase the level of payment, support, acceptance and accommodation to those claiming the disease. And let’s not forget members of the medical profession, drug companies, hospitals and other parties who have a strong vested interest in adding to the list of issues for which they may/will receive payment.

The list of syndromes, new diagnoses or disorders with expanding numbers and those claiming them are many. In no particular order they include: Post-concussive syndrome, “Low-T,” erectile dysfunction (with a recent ad featuring a beautiful woman claiming that over 50% of men over 40 suffer from some form of it), Epstein Barr Virus, Autism, Post-traumatic stress disorder, Fibromyalgia, ADHD (attention deficit hyperactivity disorder), Lyme Disease, and others. Common to many are claims of financial, educational, occupational or legal entitlement, partial exculpation from responsibility, expensive and proprietary medications, strong advocacy groups and heated arguments in the media and professions.

In short, recent “clarification” on Chronic Fatigue Syndrome likely fits more into the realm of politics than science.

One Way Other Countries Have Lowered Prescription Med Costs

What if we didn’t require insurance companies to cover all drugs? As this article suggests, companies are taking advantage of a mix of laws in the US that force insurers to include essentially all expensive drugs in their policies, and a philosophy that demands that every new health care product be available to everyone, no matter how little it helps or how much it costs.

Many European countries say “no” to a handful of drugs each year. For those of you who worry this would eliminate availability to crucial medications, of the 29 major cancer drugs included in the study that are available in the United States, about 97% and 86% are also available in Germany and France, respectively. As a consequence of the stand taken by those countries, prices in Europe for prescription drugs are 50 percent below what we pay in the US.

Because they can say no, “yes” is not a guarantee the drug will be covered, so drug companies are pushed to offer competitive pricing to ensure coverage.  A recent survey of cancer drug policies revealed you don’t have to say no very often to get discounts for saying yes, as demonstrated by Express Scripps and CVS Caremark. Read more…

 

New Year’s Resolution: Don’t Have an Annual Physical

It may sound a little odd to suggest not going to the doctor. But this editorial does just that. About 45 million American adults have a basic annual check-up. However, a study has indicated that those check-ups for adults — with no specific symptoms to discuss — are not particularly useful. In fact, the Canadian guidelines have recommended against these exams since 1979.

In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world’s biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years. Their findings? Regardless of which screenings and tests were administered, studies of annual health exams dating from 1963 to 1999 show that the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease.

There are many reasons why the annual physical is not productive; it does little to avert death or disability from acute problems; it does little for chronic conditions without significantly useful interventions; and, sadly, an early diagnosis might extend the time patients know they have cancer but is unlikely to extend their lives.

This is not to suggest skipping doctor visits altogether: get your flu shots, stay up-to-date on vaccines, discuss symptoms with your doctor.

But consider this from Dr. Ezekiel J. Emanuel, oncologist and vice provost at U. Penn: Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial. If they cannot, join me and make a new resolution: My medical routine won’t include an annual exam. That will free up countless hours of doctors’ time for patients who really do have a medical problem, helping to ensure there is no doctor shortage as more Americans get health insurance.