Are we getting too much medicine?

In all the to-ing and fro-ing about reforming the US healthcare system, scant attention has been directed at how Americans are consuming more medicine than is good for them…and evidently getting no healthier than people in other countries who spend and consume far less.

The Financial Times (Sept 16, 2009) reports that the US spends more than $1,000 per capita on pharmaceuticals, while the figure for the UK is roughly one-third of that amount. So what’s going on here? Why does the US have five times more CT scans than Germany and five times as many coronary bypass operations as France? Between 1998 and 2002, the number of CT studies in the US increased by 59%, MRI by 51%, and ultrasound by 30%.

Alexis Skoufalos, EdD, Assistant Dean for Continuing Education at Thomas Jefferson University’s School of Population Health, says that the fee-for-service model of reimbursement for healthcare services encourages physicians to perform procedures. Physicians with an entrepreneurial bent, she says, especially those in large group specialty practices, often invest in related businesses such as outpatient surgical centres or diagnostic imaging facilities.

In an intriguing article in the New Yorker (June 1, 2009) author Atul Gawande notes that spending on doctors, hospitals, drugs and the like consumes more than one of every six dollars we earn. He compares expenditures on healthcare in two similar-sized Texas towns — McAllen and El Paso.

The amount spent in El Paso was half that spent in McAllen. Gawande writes: “Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance…some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was going to come back. And by operating, they happen to make an extra $700”.

Moreover, Medicare patients received almost 50% more specialist visits in McAllen than in El Paso and were two-thirds more likely to see 10 or more specialists in a six-month period – and they received 20% more abdominal ultrasounds, 30% more bone density studies, 60% more stress tests with echocardiography, 200% more nerve conduction studies to diagnose carpal tunnel syndrome, and one-fifth to two-thirds more gallbladder operations, hip replacements, breast biopsies, and bladder scopes.

The author concludes that doctors in this country perform at least 60 million surgical procedures a year, one for every five Americans. No other country does anything like as many operations on its citizens.

Researcher Dr. Jack Wennberg started looking into all this in the 1970s. Why, he asked, did people in one town get their haemorrhoids removed five times as often as people in another town 30 miles away? Ditto with mastectomies, prostate operations, and back surgery.

Harnessing hundreds of researchers, he found, not surprisingly, that where there were more doctors, there were more medical and surgical procedures. The fee-for-service payment mechanism encourages physicians to do more, he believed, and more is not better.

But all the blame can’t be placed on doctors. As Dr Thomas A. Doyle points out in the Pittsburgh Post Gazette (Oct 11, 2009), patients must share some of it: “Healthcare costs too much in this country,” he says, “We deliver too much because we demand too much. And we demand it for all the wrong reasons. We’re turning into a nation of anxious wimps”.

And this is something aided and abetted by the pharmaceutical industry with its ubiquitous direct-to-consumer adverts contributing to expense and hypochondria. As physician Jerome Groopman points out in How Doctors Think, “the reach of drug marketing can falsely make the natural aspects of aging into diseases. Moodiness, for example, can be labeled as depression, shyness as social affective disorder, and the drive to perfection as obsessive-compulsive disorder. And as for wrinkles, here’s one: Dermatologists used to deal mainly in acne and psoriasis; now they can hardly keep up with the demand for Botox”.

Another area of high cost is the amount Americans pay for healthcare in the last 12 months of life. This accounts for some 10% of total health care expenditures; and even that varies from one state to another. According to USA Today: “If you are dying in Miami, you’ll see a specialist 46 times in your last year and the cost will be $23,000; but in Portland, Oregon you’ll go to (a mainly primary care) doctor 18 times at a cost of around $14,000”.

Clearly, we can substantially lower costs in the US health system if we could find better ways to reduce hospitalisation for people approaching the end-of-life, such as by providing more in-home services.

Writing in Health Policy, a quarterly publication of the Jefferson School of Population Health, research assistant professor, and program director, chronic illness management, JoAnne Reifsnyder, PhD, notes that communication is vital for people in the last stages of life. Without what she calls ‘death talk’ we would never have had the now decades-old hospice option.

We need to separate the policy discussion of advance-care planning from the economic costs of life-prolonging intervention, she says. She adds: “Americans have yet to answer the question of (or even ask) whether the fact that we can prolong life using technology means that we always should…We can do better – patients too often suffer needlessly when technology trumps compassion”.

Of course, we know that an aging population and increasingly sophisticated technology increase the utilisation of healthcare in the US; but other countries have aging populations. The difference is that the US clearly overuses the technology – in part because of defensive medicine engendered by doctors’ fear of litigation. Perhaps we should all realize that most conditions are self-limiting. As a wise physician once said: “Our best medicines are Tincture of Time and Elixir of Neglect”.

Dr. Woods is CEO of BioscriptUS. He is also the former editor of Health Outcomes Communicator.