November 2007
Do more, make more
"I thought I was doomed." Paul DeLeeuw, M.D., whose whole-body CT scan led to many follow-up tests but no diagnosis of serious
disease.
Photo by Roark Johnson
When it comes to health care, more is not necessarily better. But more is what patients tend to get. While America's health
system has achieved important gains against major diseases, it has also encouraged the overuse of costly treatments. The system
pays the vast majority of doctors and hospitals on a piecework basis called "fee for service." The more services they provide--a
blood test, surgery, an MRI or CT scan--the more money they make.
Experts estimate that the nation's $2 trillion annual health-care tab is one-third to one-half higher than need be, in part because of overuse of costly treatments and unnecessary care.
A glaring case in point is the rise and fall of bone marrow transplants for advanced breast cancer. Early reports of dramatic shrinkage of otherwise fatal tumors, and even some apparent long-term remissions, caused an explosion in popularity of the procedure.
Even as insurers and some experts warned that without proper clinical trials there was no proof the new treatment worked better than the old one, dozens of hospitals started programs to cash in on the demand. An estimated $3.4 billion was spent during the 1990s giving the treatment to more than 42,000 women.
But in April 2000, the New England Journal of Medicine reported the results of the first major clinical trial of the procedure: Bone marrow transplantation did not improve survival at all, but it did make patients' remaining time more miserable because of its debilitating side effects.
Bone marrow transplantation for breast cancer is now discredited, but plenty of other expensive treatments and tests are still being overused and overpromoted for all kinds of diseases.
Research conducted over the past decade by the Dartmouth Medical School Center for the Evaluative Clinical Sciences has concluded that the Medicare bill of a given community is determined in large part by its supply of medical services--hospital beds, physicians, and specialists--rather than the medical needs of its residents.
In Miami, which is well stocked with doctors and hospitals, annual Medicare expenditures in 2003 averaged $11,422 per person, compared with $5,438 in Minneapolis. Yet the Dartmouth researchers found that in regions of the U.S. that spent more on Medicare patients, the quality of care was actually worse and patients enjoyed no better outcome than in regions that spent far less.
"Hospitals are dangerous places" where patients can pick up life-threatening infections, says Elliott S. Fisher, M.D., of the Dartmouth research team. Having many different specialists is also a risk factor, probably because of a lack of communication among the various physicians.
Patients themselves are hardly clamoring for less treatment. "People will say, 'I want that new cancer drug,' even though it may not be effective," said Len Lichtenfeld, M.D., deputy chief medical officer of the American Cancer Society.
Thirty-four percent of a national sample of 300 primary-care physicians surveyed by the Consumer Reports National Research Center in August 2007 said their patients "very frequently" or "quite often" requested unnecessary or duplicative medical tests. And 66 percent said they had acceded to at least one such request within the previous month.
"We have a real cultural infatuation with the latest treatments and the latest technologies," said David Blumenthal, M.D., director of the Institute for Health Policy at Massachusetts General Hospital. "This is a fact of life in the U.S."
Paul DeLeeuw, M.D., 62, of Fort Myers, Fla., decided to have a whole-body CT scan, a screening test being promoted nationwide to spot early warnings of cancer, heart disease, and other ills. He paid for it out of pocket. Bad news: The images, he says, showed evidence of problems or abnormalities in his coronary arteries, lungs, and liver.
"I thought I was doomed," he recalls. Follow-up tests and referrals to specialists cost several thousand dollars, which insurance did cover, he says, though none led to a diagnosis of serious disease.
Sixty percent of doctors in our survey said they quite often ordered unneeded tests to protect themselves against malpractice suits.
What you can do. Designate one doctor, typically your primary-care physician, to coordinate your care.
Ask which treatments have been shown by research to be best for your condition. "When you undergo any test, inquire what the consequences are if the test is positive," DeLeeuw says.
Experts estimate that the nation's $2 trillion annual health-care tab is one-third to one-half higher than need be, in part because of overuse of costly treatments and unnecessary care.
A glaring case in point is the rise and fall of bone marrow transplants for advanced breast cancer. Early reports of dramatic shrinkage of otherwise fatal tumors, and even some apparent long-term remissions, caused an explosion in popularity of the procedure.
Even as insurers and some experts warned that without proper clinical trials there was no proof the new treatment worked better than the old one, dozens of hospitals started programs to cash in on the demand. An estimated $3.4 billion was spent during the 1990s giving the treatment to more than 42,000 women.
But in April 2000, the New England Journal of Medicine reported the results of the first major clinical trial of the procedure: Bone marrow transplantation did not improve survival at all, but it did make patients' remaining time more miserable because of its debilitating side effects.
Bone marrow transplantation for breast cancer is now discredited, but plenty of other expensive treatments and tests are still being overused and overpromoted for all kinds of diseases.
Research conducted over the past decade by the Dartmouth Medical School Center for the Evaluative Clinical Sciences has concluded that the Medicare bill of a given community is determined in large part by its supply of medical services--hospital beds, physicians, and specialists--rather than the medical needs of its residents.
In Miami, which is well stocked with doctors and hospitals, annual Medicare expenditures in 2003 averaged $11,422 per person, compared with $5,438 in Minneapolis. Yet the Dartmouth researchers found that in regions of the U.S. that spent more on Medicare patients, the quality of care was actually worse and patients enjoyed no better outcome than in regions that spent far less.
"Hospitals are dangerous places" where patients can pick up life-threatening infections, says Elliott S. Fisher, M.D., of the Dartmouth research team. Having many different specialists is also a risk factor, probably because of a lack of communication among the various physicians.
Patients themselves are hardly clamoring for less treatment. "People will say, 'I want that new cancer drug,' even though it may not be effective," said Len Lichtenfeld, M.D., deputy chief medical officer of the American Cancer Society.
Thirty-four percent of a national sample of 300 primary-care physicians surveyed by the Consumer Reports National Research Center in August 2007 said their patients "very frequently" or "quite often" requested unnecessary or duplicative medical tests. And 66 percent said they had acceded to at least one such request within the previous month.
"We have a real cultural infatuation with the latest treatments and the latest technologies," said David Blumenthal, M.D., director of the Institute for Health Policy at Massachusetts General Hospital. "This is a fact of life in the U.S."
Paul DeLeeuw, M.D., 62, of Fort Myers, Fla., decided to have a whole-body CT scan, a screening test being promoted nationwide to spot early warnings of cancer, heart disease, and other ills. He paid for it out of pocket. Bad news: The images, he says, showed evidence of problems or abnormalities in his coronary arteries, lungs, and liver.
"I thought I was doomed," he recalls. Follow-up tests and referrals to specialists cost several thousand dollars, which insurance did cover, he says, though none led to a diagnosis of serious disease.
Sixty percent of doctors in our survey said they quite often ordered unneeded tests to protect themselves against malpractice suits.
What you can do. Designate one doctor, typically your primary-care physician, to coordinate your care.
Ask which treatments have been shown by research to be best for your condition. "When you undergo any test, inquire what the consequences are if the test is positive," DeLeeuw says.
