An Epidemic of Overtreatment
By John Unger Zussman
Last month, I previewed Roger Weisberg’s new documentary about medical overtreatment, Money and Medicine, which premiered on PBS on September 25. You can view the film in full on its PBS website. In this post, I’d like to continue the discussion of the issues raised by the film and by readers’ thoughtful comments on my earlier post, with special emphasis on the politics of overtreatment.
In a particularly poignant scene in Money and Medicine, Dywane Stonum shows his elderly mother, Willie Stonum, black-and-white photos of her younger self on an electronic viewer. In one, she holds her first baby while her husband holds her. In another, she smiles proudly, decked out in an elegant jacket, a scarf tied in a bow, and a filigreed hat. “Here’s your favorite picture,” he tells her.
Willie Stonum doesn’t stir, or blink, or even acknowledge his presence.
Ten months earlier, she suffered a massive stroke. Now she languishes in her bed at UCLA Medical Center, occasionally opening her eyes. She is on a ventilator, uses a feeding tube, relies on dialysis, and needs constant medical support to maintain her blood pressure and fight pneumonia and other infections. Her Medicare bills exceed $5 million.
Dywane Stonum is his mother’s proxy for medical decisions. “I feel like my mom is my baby,” he says. “If there’s something that can sustain her medically, she would want that. Miracles happen if you believe in miracles. You do everything you can to preserve life. That’s what my mother would want.”
After ten months, UCLA’s Ethics Committee has decided that, should Willie Stonum experience another crisis, no heroic efforts should be undertaken to save her life. Dywane Stonum is incensed. “They’re pulling the plug,” he protests. “I call it a medical execution. It is euthanasia.”
“We do not practice euthanasia under any circumstances,” says Dr. Neil Wenger, chair of the Ethics Committee. But “it’s possible to use these advanced tools not to help patients, but to prolong a death, or to produce more suffering or less comfort. And under those circumstances, physicians may well say no.”
Nine years ago, my wife and I stood by my brother-in-law’s ICU bedside with his wife, daughter, and son-in-law. At age 59, after living with kidney disease for years, he had passed out and fallen in his bedroom. Although his wife quickly called 911, he had lost brain function by the time the paramedics arrived. Now we held hands and cried softly as the nurse removed his breathing tube. Minutes later, he died peacefully.
Long before his ultimately fatal illness, my brother-in-law had made this decision easy on his wife. “No way I want to live like a vegetable,” he told her, and us, and anyone who would listen. “Pull the plug. Put me out of my misery.” When he died, we felt relieved, not guilty. We were absolutely certain that’s what he would have wanted.
Leaving aside the question of why Willie Stonum is occupying a bed at UCLA—at a cost of over $16,000 a day—rather than at a nursing home, it is impossible not to wonder if she would want this kind of prolonged death—and if she ever had that conversation with her doctor or her son.
Of course, a proposal to compensate physicians to counsel their Medicare patients about end-of-life care options was originally included in the Affordable Care Act, often known as Obamacare. But when Sarah Palin falsely branded it a “death panel”—a claim that merited PolitiFact’s Lie of the Year award in 2009—it was removed from the bill.
Money and Medicine shows us two patients having just this conversation with their doctors at Intermountain Health Care in Salt Lake City. One, Davis Sargent, is suffering from end-stage congestive heart and kidney failure. “When it’s time, it’s time,” he says. “Of course I don’t want to die, but going out kicking and screaming doesn’t change the going out.” Sargent makes it clear that, instead of rescue care in an ICU, he wants hospice care at home. “I’m only 6 feet from a nice place to sit in the sun in the front yard, and I love that more than anything else.”
After his discharge, Sargent received comfort care at home for ten days before he died—as he wished—surrounded by his loved ones.
The film argues that reducing overtreatment at the end of life is not simply a question of reducing costs—it’s also what patients want when given the choice. “To deny people an opportunity to talk about death, to discuss how they want to die, to be given choices about dying, I think is a really cruel thing,” says Shannon Brownlee, acting director of the Health Policy Program at the New America Foundation, and the author of Overtreated: Why too much medicine is making us sicker and poorer. “And we have to start being able to talk about it. And not just because we’re spending a huge amount of money on it, but because a medicalized death is not what most people want.”
That sentiment is echoed by Sir Thomas Hughes-Hallett, former CEO of Marie Curie Cancer Care in the UK. “It’s not about hastening death,” Hughes-Hallett said in a recent New York Times Op-Ed. “It’s about recognizing that someone is dying, and giving them choices. Do you want an oxygen mask over your face? Or would you like to kiss your wife?”
Money and Medicine shows us overtreatment in a variety of settings and contexts. Filmmaker Weisberg argues that overtesting, overtreatment, and waste are inherent in the way we provide health care in the U.S. Our whole system is geared toward doing something rather than nothing, even when it doesn’t help or causes harm.
But there are alternatives, even within the current health-care system. Money and Medicine profiles Intermountain Medical Center, where Sargent received end-of-life counseling, as a case study in designing the best available science into care. IMC takes time to educate patients in the real risks and probabilities of both disease and treatment. And it regularly reviews practices and metrics in light of medical evidence.
For example, “elective induction of birth” by cesarean section has proliferated in much of the U.S., not for any medical reason, but for the convenience of patient and/or doctor. When IMC realized that more than a quarter of obstetrician referrals for elective C-sections were poor candidates for the procedure, they instituted team reviews of the cases. “Maybe I need my counselor who advises the surgery to not be the surgeon,” reasons Brent James, IMC’s chief quality officer. This resulted in a dramatic drop in C-sections, fewer babies in need of neonatal intensive care, and a savings of $50 million. Ironically, IMC suffered financially by receiving lower reimbursements because it performed fewer expensive procedures.
And this upside-down system of reimbursements—fee-for-service medicine—is at the core of the problem. Money and Medicine demonstrates that overtesting and overtreatment are not isolated or accidental, but 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, it’s wasteful—it consumes, by one estimate, 30% of U.S. health care spending, or $800 billion a year. But, as IMC’s James puts it, “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.
It would be one thing if overspending and overtreatment resulted in positive patient outcomes. But the U.S. achieves, at best, middling results when compared to other Western countries, while outspending them significantly. The system’s defenders like to point to foreign “medical tourists” who come to the U.S. for treatment, and the Deloitte Center for Health Solutions estimated there were more than 400,000 of them in 2008. But that number is dwarfed by the 1.5 million Americans who sought health care abroad in the same year.
Stanford geriatrician Dr. Walter Bortz blames overtesting and overtreatment on the collision of biology and capitalism in fee-for-service medicine:
I’m a capitalist, I believe in capitalism; it’s the best social contract we have to make the gears of society work. But it’s selling the wrong product. Our capitalism sells disease. We want you to bleed. Or we want you to have a spot that we don’t know, and that will generate X-ray after X-ray after X-ray … Stanford, where I love my life, is a repair shop. You go there to get fixed. Why? Because we can send you a bill for that.
The emphasis on profit means that we haven’t even done enough research to know which of our current treatments are actually working. Pharmaceutical and device manufacturers, who underwrite clinical trials, have no incentive to finance research on drugs and devices that are already making them money. “Medical research is dominated by research on the new: new tests, new treatments, new disorders, new fads, and new markets,” says Dartmouth professor Dr. H. Gilbert Welch. “We have to start directing more money toward evaluating standard practices—all the tests and treatments that doctors are already providing.”
I wish Money and Medicine had the time to show in detail the harm that can be caused by excessive screening tests and treatments, since many patients (and even doctors) discount it. What’s the downside, they reason, in getting an annual PSA or mammogram, or in receiving chemotherapy that reduces your chance of recurrence by a couple more percent? But as James says, “treatments that are powerful enough to heal can also harm.” This was illustrated last June, when Good Morning, America co-anchor Robin Roberts, who had gone public with her successful battle with breast cancer in 2007, announced that she was diagnosed with myelodysplastic syndrome (MDS). MDS is a bone marrow disease often caused by chemotherapy and radiation received in an earlier cancer treatment. “We always think of the drug as a double-edged sword,” says Otis Brawley, chief medical officer of the American Cancer Society. “It’s one of the reasons why I’m outspoken about only using chemotherapy when we absolutely need chemotherapy.” Roberts received a bone marrow transplant earlier this month.
With health care a central issue in the current presidential election, I asked Weisberg how the Obama and Romney campaigns would address the overtreatment and waste issues raised in his film. He began with Obamacare:
The Affordable Care Act that the Supreme Court recently upheld extends health care coverage to over 30 million uninsured Americans but actually does very little to make health care more affordable. The main thrust of the legislation was to expand access, not to contain costs. However, there are a number of provisions that fund demonstration projects that attempt to alter the reimbursement system in order to reward value instead of volume—to reward the quality instead of the quantity of medical services. One of the best-known initiatives involves the creation of Accountable Care Organizations or ACOs.
If the Affordable Care Act doesn’t actually do enough to make health care affordable, it’s tempting to blame Republicans and their lies about death panels. But let’s remember that the Obama administration gave away much of the store before the debate actually began, in its attempt to win support from industry and Congress. For example, in exchange for support and cost concessions from the Pharmaceutical Researchers and Manufacturers Association (PhRMA), the White House agreed not to use government leverage to bargain for lower drug prices or to import drugs from Canada.
But at least the ACOs encouraged by Obamacare take a shot at overturning the overtreatment incentives of fee-for-service medicine. Romney’s plan—to the extent he has revealed it—aims to reduce government expenditures for health care, but not the costs or structure of health care itself. Weisberg’s take:
The Romney plan, like many of his policies, is not terribly fleshed out. His mantra is “repeal and replace.” What we do know is that he would make Medicaid a block grant program, leaving states to struggle with declining budgets and decide who gets what kind of care. He would also turn Medicare into a voucher program, with the result that over time the voucher would cover a smaller and smaller portion of the medical bills of seniors.
As I write this, shortly after the final presidential debate, the campaigns have not seriously discussed medical overtreatment or cost control. In fact, so far they have not progressed beyond a fight between siblings. “You want to destroy Medicare!” “No, you do!”
Faced with governmental inaction, hospitals and professional medical organizations have begun to take responsibility for reducing overtreatment and waste in their own domains. Memorial Sloan-Kettering Cancer Center and the Mutual Of Omaha Medicare recently decided to drop an expensive new colorectal cancer drug (Zaltrap) from its formulary, despite the fact that Medicare would reimburse them for it. The reason: it works no better than a similar drug (Avastin), but costs more than twice as much.
Another ray of hope comes from the Choosing Wisely initiative, sponsored by the American Board of Internal Medicine Foundation. The initiative has recruited professional associations for major medical specialties, like the American Association of Cardiology and the American Society of Clinical Oncology. Each association has identified “Five Things Physicians and Patients Should Question”—common tests or treatments that are expensive, overused, and unsupported by medical evidence. Working with these professional societies, Consumer Reports has compiled clear and objective guidelines for patients 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. (My thanks to Cameron Ward for alerting me to this site in a comment to my earlier post.)
Some commentators maintain that, to truly control health care spending in the U.S., we need to ration health care. “In the famous ‘third rails’ of American politics,” argues Steven Rattner, former counselor to President Obama’s treasury secretary, invoking the spectre of death panels, “none stands taller than overtly acknowledging that elderly Americans are not entitled to every conceivable medical procedure or pharmaceutical.”
In the long run, that’s probably true. But we’re not there yet—not even close. There’s plenty of low-hanging fruit to pick first. “It’s not rationing to get rid of stuff that’s bad for you,” says Brownlee, author of Overtreated. “It’s not rationing to get rid of care that won’t benefit you.” In the film, she cites a recent study of late-stage cancer patients that compared palliative care—making the patient comfortable without actively trying to combat the disease—to standard, aggressive treatment. The patients who received only palliative care actually lived longer than those who received the standard treatment.
“This isn’t withholding necessary care,” echoes IMC’s James. “It’s withholding unnecessary injuries.” Eliminating overtesting and overtreatment have little downside and great upside. But to do that, we need to rely on science to sort out which tests and treatments are medically warranted. And we need to eliminate the incentives of fee-for-service medicine and embrace an ACO model in which healthy outcomes, not tests and treatments, are rewarded.
It’s time to have that “adult conversation” our leaders keep promising—whether they choose to participate or not.
Copyright © 2012, John Unger Zussman. All rights reserved.