Is More Health Care Better?

Is More Health Care Better?
Money and Medicine
By John Unger Zussman

I never envisioned our life together to be possibly shortened. We were looking at cruising off into the sunset and we’re still actively raising children! And here you are and you have this diagnosis, and it’s just hard to do.

John’s tearful, anxious wife speaks these words to him as she stands beside his gurney at UCLA Medical Center in Roger Weisberg’s new documentary film, Money and Medicine. (It premieres on PBS this Tuesday, September 25.) John appears healthy and fit at 55, but a recent routine screening test detected an elevated level of prostate specific antigen (PSA), and a biopsy confirmed prostate cancer. Of several treatment choices, he elected the most aggressive option. Now he wears a surgical cap and is waiting to be wheeled into surgery, where his prostate will be surgically removed.

John understands the risks—the surgery may leave him impotent, incontinent, or both—but he considers himself fortunate. “If I had to have a tumor of this sort,” he says, “this is a much easier one to find at an early stage, and to be able to take aggressive action against it.”

I’ve blogged about cancer before, after someone close to me—I called her Bonnie—was diagnosed with breast cancer. That first diagnosis scared the hell out of Bonnie (and me). Cancer is cast as a frightening demon in our society, the focus of our collective paranoia. We think of it as a death sentence, and our impulse is to unleash the heavy medical artillery in an attempt to eradicate every last cancer cell from our body. John’s treatment decision is easy to understand.

But it’s based on a false assumption. Not all cancers will kill you. Your immune system may take care of it on its own, based on evidence that some breast, testicular, and other tumors, left untreated, regress or disappear. Other tumors—especially prostate cancer—seem content to hang around without spreading significantly for years or decades. Most elderly men die with prostate cancer—it’s found in their autopsies—but it wasn’t the cancer that killed them.

That’s why there’s such controversy over mammography and PSA tests lately. An elevated PSA test puts men on a track for invasive testing and risky treatment that may not help them at all. According to the physicians in the film, there’s no way to predict which cancers will spread aggressively and which will sit there harmlessly. “You have to remove about fifteen prostates to prevent one prostate cancer death,” says Dr. Michael Barry of the Foundation for Informed Decision Making. “The problem is, at the individual level, all fifteen of those men will think it was them whose life was saved. One of them is right, fourteen are wrong—but we don’t know which one.”

Ten months after the surgery, John defends his decision. “I believe that I may be one of the people whose life was saved, or at least extended, by going in aggressively,” he says. “Going into the surgery, I was aware of potential side effects—that I might be giving up some things that I would rather not give up. As it’s turned out, I did give up something. And I might be one of the fourteen for whom this wasn’t particularly lifesaving or in any way important. But prostate cancer kills people, and I would do it again.”

In John’s view, impotency or incontinence was a price he was willing to pay to eradicate the cancer. But there is an alternative to aggressive treatment, called “watchful waiting,” in which patients undergo no treatment but are regularly monitored, via blood tests and biopsies, to detect any spread of the cancer. The film shows another prostate cancer patient, at Intermountain Medical Center in Salt Lake City, reviewing treatment options with members of an interdisciplinary team of specialists. Once he’s informed about the real risks and probabilities of both disease and treatment, he happily chooses watchful waiting. But currently, only 10% of prostate cancer patients choose this option.

The value of watchful waiting was validated recently—too recently to affect John’s surgery decision—in the prestigious New England Journal of Medicine. Early-stage prostate cancer patients who were randomly assigned to a watchful waiting regime were equally likely to survive through the 15 years of the study as men assigned to surgery. Some men who did nothing died, as did some men who had surgery. But there was no statistical difference between the two groups.

In my earlier essay, I argued fiercely that Bonnie should be able to make her own treatment decision, based on an informed evaluation of what was right for her. John deserves the same respect, and neither filmmaker Weisberg nor I would presume to tell him that his surgery didn’t save his life. But the statistical probability is that it didn’t.

Instead, Weisberg’s film makes a larger point. Our whole health care system is geared toward doing something rather than nothing. This results in overtesting, overtreatment, and waste.

Money and Medicine shows us overtreatment in a variety of American medical settings and contexts, from the beginning of life (where “elective induction” by Caesarian section has proliferated) to the end (where one-third of medical costs are incurred). It also surveys the 95 million imaging studies (mammograms and other X-rays, CT scans, MRIs, and more) conducted in the U.S. every year.

Weisberg is an accomplished, veteran documentarian whose films air regularly on PBS. His work has won numerous awards, including two Academy Award nominations. He knows how to let his subjects tell their own story, without getting in the way. He has addressed the health care crisis before, most recently Critical Condition in 2008. I reviewed his film on capital punishment, No Tomorrow, in this space last year. (Full disclosure: he is also a long-time family friend.)

The overarching theme of Money and Medicine is that these cases of overtreatment are not isolated or accidental. Overtesting and overtreatment are integral parts of the American medical system. Every decision, every incentive—for patient, doctor, hospital, pharmaceutical and device manufacturer, insurer, and politician—is weighted toward doing more rather than less, even if it causes harm.

Of course, overtreatment is wasteful—it consumes, by one estimate, 30% of U.S. health care spending, or $800 billion a year. But, in the words of Dr. Brent James, chief quality officer at Intermountain Health Care, “one person’s waste is nearly always another person’s income.” In fee-for-service medicine, no one gets paid unless the test is ordered, the medication is prescribed, or the procedure is performed.

There’s much more to say about overspending and overtreatment in the American health care system. But let me end now and give you a chance view the film. I’ll come back to initiate a dialogue with further comments.

Money and Medicine debuts on PBS this Tuesday, September 25, 2012; be sure to check local listings. Visit the film’s PBS website to view the trailer and download the viewer guide.

Copyright © 2012, John Unger Zussman. All rights reserved.

About John Unger Zussman

John Unger Zussman is an award-winning screenwriter, creative writer, and technical writer from Portola Valley, California. His essays have been published in The Sun Magazine. He has won a Grammy Award (as a member of the San Francisco Symphony Chorus), but there’s room on the shelf for an Oscar and a Pulitzer. John also works as a corporate storyteller in info and biotech and holds a PhD in Psychology from Stanford University.
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5 Responses to Is More Health Care Better?

  1. Edie says:

    John, this is exc ellent writing. I hope to watch the film although our station is currently fund raising and it is rare to see anything good when they do. Derwin and I are both at the age where we are looking at some of these decisions. Neither of us want extraordinary measures at the end of life and we are in process of putting the paperwork we need in order. For years he has told me that he wouldn’t get prostate cancer treated since what you state is true. I also had a cousin who died around the age of 90 of had had prostate cancer for a very long time. He was laughing and walking around until the last day of his life, enjoying every minute and living fully.

    In light of your experience and because I desire universal care for all, I think that more of us who will accept palliative care(not neglect) and die without machinery and hospitals making us and our loved one miserable, could help to lower costs and face death in a more peaceful and dignified way.

  2. Jane Churchon says:

    As a nurse, I have strong opinions about this subject, because it is painful to see people’s decisions influenced by a mixture of ignorance, fear, hope and tiny bits of knowledge. When 95% of our money goes toward end-of-life care, as a nation, we are doomed to neglect our non-end-of-life care in a world of shrinking healthcare dollars and increasing healthcare gadgetry. Too many hospitals have robotic surgery available to consumers, for instance, with little hard evidence that it improves the patients’ experience or shortens length of stay (despite claims otherwise). Yet, hospitals without robotic surgery can’t compete in a tough market, forcing the cost of prostate and gynecological cancer care upward, even for those patients who don’t use surgeons operating the robot.

    How many healthplans pay for nutritional counseling and support for their patients? Do any pay for gym membership? How much money would we save if these services were available to all of us?

    More importantly, which physicians are going to say no to care when there is the slimmest of hopes that it will help his/her patient? Who is willing to be accused of being a member of “a death board”?

  3. Peter Merriman says:

    John,
    You bring up a very important issue that our health care system is geared toward over-treatment!

    Watchful waiting is a good antidote in cases of prostate cancer, but how do we deal with the remainder of health issues? We need to reward quality outcome and replace the pay for procedure systems. The concept gets mentioned, but fails to get traction in the discussion.

    Im hoping someday (maybe you?) wil articulate a better path. Great writing John, I hope we get to read more of it.

    Peter

  4. Cameron Ward says:

    Thank you, John. I passed your article to a doctor friend involved in the issue of the health of the health care system. He appreciated the article, and referred me to http://choosingwisely.org/, an effort Consumer Reports and many medical associations are involved in to bring attention to the issue of overuse of the health care system.

    Cam

  5. John Unger Zussman says:

    Thank you all for your thoughtful comments and suggestions. The incentives for overtreatment are both systemic and individual. Eliminating fee-for-service medicine in favor of promoting healthy choices (like gym membership) and rewarding healthy outcomes, as Peter and Jane suggest, are important and necessary structural changes.

    But perhaps the first step is educating patients about both the benefits and harm of particular tests and procedures. I’m very impressed by the clear and objective information on the Choosing Wisely site Cam highlighted, on such topics as heartburn, Pap tests, and lower back pain. As the film suggests, when patients are informed about the choices available to them and their risks and benefits, they are less likely to choose overtreatment. This is especially true of end-of-life care, as Edie points out. If we can get beyond accusations of “death panels” and help doctors truly inform their patients, we can reduce waste, cut costs, and provide better outcomes.

    Stay tuned. I hope to address some of these issues in my next post.

    John

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