When a pound of cure is too much
Another phase of the US healthcare crisis: patients who are overtreated.
Most Americans know that the healthcare crisis in the United States is a two-headed monster: First, medical care is too expensive. And, largely because it's so expensive, that care doesn't reach millions of people who are poor or uninsured.
But what few may realize is that the crisis has an ugly third face: Many Americans receive too much medical care. Those excess pills, heart stents, MRIs, radical mastectomies, and other treatments not only are often ineffective and waste hundreds of billions of dollars, they also sometimes harm the patients they are intending to help.
That's the fascinating, counterintuitive, and potentially revolutionary conclusion of award-winning science journalist Shannon Brownlee in Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. A reader is likely to come away agreeing with Brownlee that reform of the $2.1 trillion American healthcare industry – already the size of the entire economy of Italy and rapidly growing – will never happen unless some uncomfortable truths are confronted.
•A shockingly tiny proportion of medical treatments and drugs have strong scientific evidence of effectiveness to back them up. Dr. David Eddy, a heart surgeon and healthcare economist, estimates "that as little as 15 percent of what doctors do is backed up by valid evidence." The prestigious Institute of Medicine, Brownlee adds, "estimates that only 4 percent of treatments and tests are backed up by strong scientific evidence; more than half have very weak evidence or none."
•The amount and type of "care a person receives depends less on what kind of care he needs and more on where he happens to live." That conclusion has been documented in decades of groundbreaking statistical research conducted by Dr. John Wennberg at Dartmouth Medical School and others. It shows that individual doctors take highly varied approaches to treating diseases based more on hunches than solid research.
•Despite Americans' eagerness to gain access to specialists, "the more specialists involved in your health, the more likely it is that you will suffer from a medical error, that you will be given care you don't need and be harmed by it."
•Unlike in other industries, the introduction of new technologies into medicine usually doesn't bring costs down, but boosts them.
The bottom line? Americans spend between one-fifth and one-third of their healthcare dollars – $500 billion to $700 billion – on medical care "that does nothing to improve our health," Brownlee concludes.
Brownlee, a former US News & World Report health reporter, has won several prestigious journalism awards, including the 2004 Association of Health Care Journalists Award for Excellence in Health Care Journalism and the Victor Cohn Prize for Excellence in Medical Science Reporting. In "Overtreated," which New York Times economic columnist David Leonhardt recently called the best economics book of 2007, she takes a cleareyed look at some baffling questions.
Why do people allow themselves and their loved ones to be overtreated? Insurance coverage makes many people feel that someone else is paying and that they might as well wring all the services they can out of their coverage. Patients trust that their doctors will have only their best interests at heart and not recommend useless or unnecessary treatment.
Doctors, in turn, risk malpractice suits if they withhold a treatment requested by a patient, however unlikely it is to be of help. Sophisticated marketing campaigns by drug and medical device companies, aimed at both average Americans and their doctors, lobby hard to increase the use of new medicines and devices, even if they are no more effective, and possibly more dangerous, than earlier forms of treatment.
The result is that Americans spend about $6,000 per person on healthcare annually, roughly 2-1/2 times more than the median for the rest of the industrialized world. Americans also swallow 25 to 50 percent more prescription drugs per capita than do Canadians or Europeans. Yet the average life expectancy of Americans, at 77 years, is lower than in Western Europe, Canada, or Japan and closer to that of Cyprus, Costa Rica, and Chile.
The costs are more than merely financial. One estimate, Brownlee says, ascribes the number of deaths of Americans from unnecessary medical care at 30,000 per year. And an influential Institute of Medicine report released in 1999 called "To Err Is Human" estimated that as many as 98,000 Americans are killed each year by medical errors.
What this means is that ineffective medical treatments are more than just a waste of time and money: They raise the risk of harm to patients.
A lack of solid, unbiased information exacerbates the problem, Brownlee says. Patients rely on doctors for advice, and doctors rely on medical journals. But many physicians lack the training they need to assess the science in journal studies.
What's more, some 80 percent of the studies are funded by drug companies, which means that at the very least they need a thorough and skeptical review before publication. But peer reviews of journal articles, conducted by experts in the field, have seen embarrassing failures in recent years.
Even the news media has failed to play its watchdog role. Reporters are themselves courted by medical companies seeking favorable coverage. Brownlee quotes medical journalist Trudy Lieberman, who points out that reporters "share the American cultural belief in the inherent goodness of medicine and its corollary – that every new pill, every new treatment, works and should be treated as safe and effective until proven otherwise."
What can be done? Electronic medical records for each patient could ensure fewer hospital errors (such as the wrong drug or wrong dosage) and bolster best practices. (A shockingly low percentage of patients in hospitals actually receive what is considered the best treatment for their ailment.) The Veterans Health Administration has a model electronic-records system in place.
"Evidence-based medicine" – basing treatment on solid scientific research that suggests what really works and what doesn't – must become more commonplace. And hospitals and doctors must be paid for how well they care for their patients as a whole, not merely based on how many pills, surgeries, or tests they provide.
Americans, Brownlee concludes, don't need more medicine. They need better medicine.
• Gregory M. Lamb is on the Monitor staff.