Is too much medicine the real cause of the U.S. health care crisis?

Americans are addicted to doctors. The U.S. spends more on health care—and gets less for it—than any other wealthy country. The $2 trillion that we spend every year buys us a national health care system ranked 37th by the World Health Organization as well as the second worst infant mortality rate and the lowest life expectancy among industrialized nations.

Surprisingly, a big part of the problem is that many Americans receive too much health care, not too little: too many doctor visits, too many tests, too many surgeries, too many medications. The result is excessive medical mistakes and patient casualties. Overtreatment kills at least 30,000 people every year according to government statistics, causes unnecessary pain and suffering for many thousands more and wastes billions of dollars.

Although presidential candidates of both parties are obsessed with the challenge of national health insurance, overtreatment might actually affect more people than under-insurance.

“We spend between one-fifth and one-third of our health care dollars…on care that does nothing to improve our health,” said Shannon Brownlee, medical journalist and author of Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer. “Unnecessary treatment and tests aren’t just expensive, they can also harm patients.”

Last year, for example, a healthy 3-year-old boy walked into a Florida clinic for tests to determine why he was short for his age: Only two days later, he was dead from an overdose of a normally safe amino acid.

In her book, Brownlee tells the story of a 37-year-old man who was admitted to Alleghany General Hospital in Pittsburg with an inflamed pancreas. After four days in the hospital, he developed an infection from the intravenous line connected to his groin, which led to numerous surgeries and 83 more days of hospitalization.

Furthermore, more than 2 million children took prescription drugs in 2006 for acid reflux—spitting up—partly because of intense pharmaceutical advertising. One expert described it as “grossly over-prescribing” for what is more of a “laundry” issue than medical one.

The medical literature provides plenty of detailed evidence that suggests the full breadth of the problem.

A study of Ohio elderly showed that 24 percent have received catheters for no reason, and that those needless procedures often lead to infections and other complications. A study from Georgetown University estimated that Americans on the whole pay as much as $250 million every year for tests that are unnecessary or not recommended during routine physicals.

In the same spirit, Americans undergo 60 million CT scans every year, one-third of which are estimated to be unnecessary. According to a study published in The New England Journal of Medicine, all that excess radiation is likely leading to more cancer.

Medical mistakes compound the problem of overtreatment. According to the Institute of Medicine of the National Academies of Science, medical errors in the U.S. kill as many as 98,000 people every year. These mistakes are the third leading cause of death in the country, after heart disease and cancer.

Of course, most doctors are not greedy, most hospitals are not incompetent and most patients are not worse off when they walk out of a medical center. However, enough of them are to make the American medical system an unnecessarily dangerous place.

In our interactive graphic, find out about the five real causes of overtreatment.Watch a video interview with Shannon Brownlee, whose thorough research on the subject has illuminated both the causes and outcomes of the epidemic of overtreatment in the American health care system. Unequal Treatment

Shannon Brownlee and other researchers have amassed considerable evidence to demonstrate the way a person is treated is directly influenced by where they live.

 

Case 1: Tonsilitis

In 1973, John Wennberg and Alan Gittelsohn published a seminal study in Science describing drastic variations in health care among adjacent communities. In Middlebury, Vt., only 7 percent of children under 16 had their tonsils removed. Seventy-five miles away, in Morrisville, Vt., that figure was 70 percent, with no evidence that the Morrisville kids were any different from those in Middlebury.

 

Case 2: End-of-Life Treatment

In Overtreated, Brownlee documents tremendous disparities in end-of-life treatment between patients at the University of California, Los Angeles and the University of California, San Francisco medical centers.

In the last six months of their lives, UCLA patients had doctor appointments 93 times, and spent 23 days in the hospital and 11 days in the intensive care unit. In contrast, UCSF patients saw their doctors only 30 times, and spent 11 days in the hospital and 3.3 days in the intensive care unit.

There was no reported difference in the quality of care or in patient needs.

 

Case 3: Prostate Cancer

BMJ, a leading British medical journal, published a study in 2002 that compared the incidence of prostate cancer screening and treatment among older men aged 65–79 in Seattle versus Connecticut. Men in Seattle were 5 times more likely to be tested and twice as likely to be operated on for cancer than men in Connecticut.

However, all that extra surgery did not help the Seattle men to live longer; although it presumably did make them much less comfortable and probably poorer as they aged.

 

Case 4: Spine Surgery

Florida has long been a popular destination for retirees, which leads to lots of surgery on aging backs, knees and hips. In 2004, the journal Health Affairs published a study that stated that the likelihood of being operated on is mostly a function of whether a patient lives in east or west Florida.

People in Bradenton, on Florida’s west coast, are 2.3 times as likely to have back surgery and twice as likely to have knee or hip surgery than people who live in Miami on the east coast. Fort Myers residents, on the west coast, are 1.5 times as likely to have back or knee surgery than residents of Fort Lauderdale.

Why? It seems that doctors on the Gulf coast just like to operate more.

 

A Culture of Excessive Testing

Americans trust their doctors.

The doctors, however, know they over-test and overtreat. Two-thirds of physicians recently surveyed by Consumer Reports said they had ordered at least one unnecessary test in the past month, just because their patients asked.

How do doctors explain overtreatment? The most straightforward answer, according to Dr. Joseph Scherger, a contributing blogger for Revolution Health and professor at the University of California, San Diego, is that “we train doctors to overtreat patients.”

Dr. Scherger said excessive treatment is part of medical school culture, especially among specialists. Scherger believes specialists feel compelled to order a lot of tests, or “they are not being a proper specialist.”

Dr. Gilbert Welch, author of Should I Be Tested for Cancer? Maybe Not and Here’s Why, agreed, adding that “overtreatment is the consequence of over-diagnosis.” He said that cancer screening identifies many cancers that won’t develop into advanced life threatening strains.

Once diagnosed, however, treatment almost inevitably follows, even if the side effects are dramatic. For example, even very early signs of prostate cancer are treated with a procedure called a radical prostatectomy, which often results in incontinence and impotence.

Dr. Scherger pointed out that many doctors use testing to protect themselves against malpractice lawsuits. One doctor explained on KevinMD.com that his wife’s doctor ordered a wound culture, an ultrasound and a biopsy when a scratch on her breast looked like it might be infected. “My wife already knew that this was all cover-your-ass practice of medicine.”

Money also plays a role in shaping doctors’ behavior. Managed care—which places health insurance companies in the middle of the doctor-patient interaction—has transformed how doctors are compensated.

A typical example was reported by the journal Health Affairs. In 1984, an obstetrician paid $18,000 for malpractice insurance and charged $2,800 per delivery. Twenty years later, he paid $140,000 in insurance while insurance companies only let him charge $1,600 per delivery.

To offset the lower fees, many doctors overbook their schedules, provide prescriptions on demand and garner extra income by doing more procedures.

Brownlee documents how doctors now invest in laboratories, rehab centers, and new equipment, such as EKG machines. The economics are obvious: An EKG machine costs about $1,000 and generates $24 each time it is used.

One result, Brownlee writes, is that the number of elective procedures performed around the country rose dramatically between 2000 and 2005.

Unfortunately, there is scant evidence that Americans are healthier as a result. The National Stroke Association said that carotid endarterectomies—a widely performed vascular procedure—increases the possibility of stroke for patients with moderately blocked arteries. Yet, vascular surgeons performed about 88,000 unnecessary procedures in 2002.

 

Listen to the experts: four top medical professionals weigh in on the symptoms of overtreatment and how we can fix it.Click around our diagnostic form to find out how the average check up and physical has changed in the last 20 years.

 

Pushing Pills for Profit

Americans spent over $275 billion on prescription drugs in 2006 and an estimated $300 billion in 2007—more than any other industrial country. And according to the McKinsey Global Institute, not only do Americans consumer more drugs, they pay more for them as well.

Because of the way the U.S. regulates prices, the cost of prescription drugs are 50 to 70 percent higher than those in comparable markets. The other factor driving up drug prices is a widespread preference for the latest, typically most expensive brand of medication, even though most “new” Food and Drug Administration (FDA) approved drugs are typically just slightly revised versions of existing medicines.

The national preference for these flashy prescriptions isn’t accidental. Overall, drug companies spend more than $30 billion per year promoting their products. Although the largest share of advertising dollars goes directly to doctors, the average consumer now spends 30 hours per year watching television ads paid for by Big Pharma. Magazines and prime-time television are inundated with ads for drugs with exotic names, such as Abilify (for bipolar disorder), Lipitor and Zetia (cholesterol), or Cymbalta (depression). Of course, patients can’t buy any of them without a prescription, so the advertisements typically end with the instruction to “ask you doctor if this medication is right for you.”

Drug companies spend roughly $5 billion per year on these direct-to-consumer ads. Clearly, it is money well spent: According to Dr. Ray Strand, author of Death by Prescription, doctors order the drugs that their patients request as much as 70 percent of the time.

Presumably, the FDA is supposed to protect Americans from the potential for conflicting interests and other risks from too much medicine. But On Nov. 29, 2007, the agency announced that unfortunately it “suffers from serious scientific deficiencies and is not positioned to meet current or emerging regulatory responsibilities.”

Now they tell us.

 

Shocking the System

Heath care costs may reach $4.1 trillion by 2016, a fiscal impact that could collapse our current system.

Whoever wins in November, odds are good that reforming health care insurance will be a top priority for their administration. The dilemma is that only addressing the challenge of the uninsured would risk overwhelming a system that is already near its breaking point.

However, experts don’t agree on the solutions. There are many good ideas being debated, most of which center on refocusing the system on results rather than processes. With 56 million Americans expected to be without health care insurance by 2013, something must be done. These are some of the ideas.

Primary care providers should be paid to manage patients’ care through the delivery system. Hospitals and health care providers should be given incentives to produce high-quality care. Patients and their advocates should have easy access to price and quality information.

Weeding out bogus malpractice claims might help to reduce insurance costs and relieve some of the pressure on doctors to overtreat. At the same time, payments for actual medical errors should be eliminated. Adoption of electronic medical records to provide patient information in real time would help reduce errors and excess testing. And changing how drug companies are regulated is critical to getting costs under control.