Dr. Atul Gawande has done it again.
Writing in the New Yorker, Gawande, a general surgeon at Brigham and Women’s Hospital in Boston, author and MacArthur Foundation “genius grant” recipient, painstakingly explains the “epidemic of unnecessary care” that bears much of the blame for the country’s runaway healthcare costs and preventable deaths.
Gawande also looked at strategies for combat the problem, and found, to the surprise of nobody in the healthcare industry, that moving away from fee-for-service toward accountable, outcomes-based care is absolutely necessary. He just had no idea just how effective an incentive shift could be until he took a deeper look at the evidence.
As Gawande noted, the Institute of Medicine reported in 2010 that 30 percent of healthcare spending, or $750 billion a year, was wasteful. “The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary healthcare services,” Gawande noted.
More recent research has corroborated this finding. Gawande said that he reviewed the records of eight patients he saw on the day he read a new report. Seven of them had received unnecessary care — including “inappropriate” surgeries — he concluded. Yet, the public seems blissfully unaware of how pervasive the problem is.
“Why does this fact barely seem to register publicly? Well, as a doctor, I am far more concerned about doing too little than doing too much,” Gawande wrote. “It is different, however, when I think about my experience as a patient or a family member. I can readily recall a disturbing number of instances of unnecessary care. ”
Often, making a correct diagnosis and providing appropriate treatment comes down to obtaining a proper history, according to Gawande. Other times, fee-for-service reimbursement is to blame, while sometimes patients just want peace of mind. Usually, it is a combination of factors.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
“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,” Gawande wrote. “Experts recommend against doing electrocardiograms on healthy people, but millions are done each year, anyway.”
This overtesting also has led to a problem Gawande referred to as “overdiagnosis.” As he explained: “This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. … For instance, cancer screening with mammography, ultrasound and blood testing has dramatically increased the detection of breast, thyroid and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.”
Still, patients would rather their doctors order too many tests rather than too few, lest something serious gets overlooked.
“It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative,” Gawande said.
The Harvard surgeon did find some glowing examples of where incentives have changed to encourage the provision of “necessary” care and no more.
Walmart takes a lot of heat for allegedly putting profits over the well-being of its employees, but the world’s largest retailer has saved a lot of money and achieved better outcomes by structuring health benefits to encourage enrollees to go to one of six “centers of excellence” around the country for spinal, heart or transplant surgery. “Two years into the program, an unexpected pattern is emerging: the biggest savings and improvements in care are coming from avoiding procedures that shouldn’t be done in the first place,” Gawande said.
Gawande then returned to McAllen, Texas, to see that costs had come way down from 2009, when he examined the reasons why the Dartmouth Institute for Health Policy and Clinical Practice had declared the border town the most expensive healthcare market in America.
He found that dedicated primary care can reduce death rates dramatically. He also found that accountable care seemed to be working, as the two ACOs in the McAllen area have saved Medicare $26 million, and, under the Medicare Shared Savings Program, 60 percent of the money went back to the two groups.
Sure, there are skeptics of reducing testing, including those physicians and hospitals fearful of lawsuits for being negligent.
“It’s possible that we will calibrate things wrongly, and skate past the point where conservative care becomes inadequate care. Then outrage over the billions of dollars in unnecessary stents and surgeries and scans will become outrage over necessary stents and surgeries and scans that were not performed,” Gawande said.
“Right now, we’re so wildly over the boundary line in the other direction that it’s hard to see how we could accept leaving health care the way it is. Waste is not just consuming a third of healthcare spending; it’s costing people’s lives,” he countered.
