Published Mar 5, 2010
From the magazine issue dated Mar 15, 2010
When the White House and Congress were struggling last year to keep the cost of health-care reform from exploding, they got most of the industry to ante up. Pharma agreed to give up $80 billion in revenue over the next decade, hospitals kicked in $155 billion in foregone Medicare and Medicaid payments, and medical-device makers grudgingly agreed to a $20 billion tax. But one big player refused to put any money on the table: doctors. The American Medical Association pledged to support health-care reform only if its members' incomes didn't take a hit.
That doctors demanded protection for their wallets strikes Howard Brody, a family physician at the University of Texas Medical Branch, as "ethically questionable," and not only because he thinks doctors have a moral obligation to help get the nation's health-care bill under control. The bigger problem is that "doctors rip off the system with inappropriate care," says Brody. An estimated one fifth to one third of U.S. health-care costs, at least $500 billion a year, goes toward tests and treatments that do not benefit patients—routine CT scans in the ER, antibiotics for colds, Pap tests for women who do not have a cervix, and …
What comes after the ellipsis is the question of the hour. Brody recently proposed, in The New England Journal of Medicine, that every medical specialty identify five procedures—diagnostic or therapeutic—that are done a lot and cost a lot but provide no benefits to some or all of the patients who receive them. Five is just a suggestion, high enough to be meaningful but low enough to exclude procedures in which the science is still open to debate, such as annual mammograms for women under 50. "I'm pretty convinced that each specialty could come up with 15 or 20, but in calling for five I think we can find uncontroversial ones," says Brody. It's not just about saving money, either. Any time a doctor performs a procedure, there is the risk of medical error and side effects, such as an elevated risk of cancer from CT scans. Unnecessary care kills 30,000 Americans every year, estimates Dr. Elliott Fisher of Dartmouth Medical School—and that figure includes only Medicare patients.
Medical groups have not exactly beaten a path to Brody's door, so NEWSWEEK contacted several to see if they would play along. Reactions ranged from "we do no unnecessary care" (dermatology) to "only five?!" (emergency medicine). Allen Lichter, CEO of the American Society of Clinical Oncology, nominates what he calls "nth-line therapy"—the third or fourth or fifth chemotherapy drug for a patient whose cancer has not been felled by the first or second. "I don't know what n should be," he says. "But at some point chemotherapy has an extremely low chance of extending life and a high chance of shortening life due to toxicity."
Experts in internal medicine are already well along in identifying items for Brody's list. "I hate to say it, but it's true: doctors sometimes do things that do not benefit patients and can even be harmful," says Stephen Smith of Brown University medical school, who is spearheading the effort. Nominations, all from physicians, include antibiotics for upper-respiratory infections (the drugs kill bacteria, not the viruses that cause colds), Pap tests for women under 21 ("solid research shows that they find things that lead to unnecessary interventions but would clear up on their own," says Smith), and me-too drugs that are no more effective than older versions (anything other than diuretics for first-line treatment of high blood pressure).
High-tech tests are also in Smith's crosshairs. For coronary calcium scans, he says, "there is no evidence they lead to better outcomes. In low-risk patients, high coronary-artery calcification still means the patient is at low risk for heart disease and nothing needs to be done other than the usual 'heart healthy' behaviors. In a high-risk patient, aggressive efforts at reducing risk factors need to be undertaken regardless of the coronary-artery calcification." Similarly, thyroid testing in a patient with no symptoms "rarely yields an abnormal result," Smith says, and so "is not worth doing" on a symptom-free patient. Smith's team will "field test" these and other nominees this spring by asking hundreds of doctors if they agree. Eventually, docs who pledge to avoid unhelpful procedures might display some sort of emblem.
Smith's group is also considering nixing X-rays and MRIs for lower-back pain: the scans often spot something that is unrelated to the pain. About 80 percent of adults over 40 have a bulge or other deformation in their lower back that makes surgeons think "operate"—but no pain. So when such an "abnormality" shows up on a CT or MRI, attributing a patient's pain to it is probably nonsense. In fact, the vast majority of lower-back pain is caused by muscle sprains and strains that don't show up on scans, and for which surgery is no more effective (and is more dangerous) than over-the-counter pain meds, time, rest, and exercise. Although lower-back pain typically resolves within six weeks, many patients refuse to wait, and surgeons and radiologists have financial incentives to see that they don't. A 2009 study found that Americans spent $85.9 billion for imaging, surgery, drugs, and doctors' visits for lower-back pain—most of it for no benefit. "The use of MRI within six weeks of the start of lower-back pain is not only not useful, but it increases the number of surgeries, treatments, and costs," says anesthesiologist Ray Baker, president of the North American Spine Society, whose members do those very things.
Baker, who "applauds" Brody's call to arms, believes there are enough data to "draw a circle around" other procedures that are his members' bread and butter. For instance, at least 351,000 spinal fusions were performed in 2007, reports the Agency for Healthcare Research and Quality, at a cost of $26.2 billion. Yet except in the tiny fraction of cases in which the pain is caused by fracture or tumor, they're useless—but financially irresistible, points out Shannon Brownlee in her 2007 book Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. At $75,000 per spinal-fusion procedure, medical-device makers, hospitals, and surgeons have every reason to keep the gravy train rolling. "We doctors are extremely good at rationalizing," says Brody. "Somehow we manage to figure out how the very best care just happens to be the care that brings us the most money."
Doctors who want to eliminate unhelpful procedures have their scalpels aimed at several other surgeries. Brody nominates arthroscopic surgery for osteoarthritis of the knee. A 2004 study showed that it is no more effective at restoring mobility and reducing pain than sham surgery. In other words, all the benefits reflect a placebo response on the part of patients, who think, "Docs in surgical scrubs, high-tech surgery, gleaming OR—this will certainly help me." But orthopedic surgeons still do the surgeries, which cost about $6,000.
They are not the only physicians who ignore the findings of clinical trials. Two studies last year in the NEJM showed that vertebroplasty, in which cement is inserted through a needle into the spine to stabilize vertebrae, is no more effective at reducing pain and disability than fake surgery (anesthesia, small incision for the needle, no cement). That suggests it is the hope and expectations of patients, not the procedure, that help. Yet about 170,000 vertebroplasties are done every year, at a typical cost of $5,000. Surgeons protest that their vertebroplasty patients hug them in relief that their pain has vanished. But "we saw 'miracle cures' in the sham-surgery group, too," says David Kallmes of the Mayo Clinic, who led one of the studies.
Every year cardiac surgeons perform bypasses on thousands of patients who have one or two blocked arteries, and cardiologists do angioplasty (with and without stenting) on thousands more. But five large clinical trials have shown that, except in an emergency, inserting a stent (to prop open a clogged artery) does not reduce the risk of heart attack or death any better than treating with drugs first (and stenting only if the pain persists). Interventional cardiology nevertheless carries on to the tune of about 500,000 elective angioplasties a year, at $51,000 each, including in patients who should get drugs instead. Hospitals can get $20,000 from private insurers for angioplasty, Brownlee found, almost half of which is pure profit. "Advocates say, 'We do it differently' or 'The clinical trials focused only on particular populations of patients, and we do these surgeries only where appropriate,'?" says Nortin Hadler, professor of medicine at the University of North Carolina and author of the 2009 book Stabbed in the Back: Confronting Back Pain in an Overtreated Society. "These arguments walk a fine line between hubris and quackery."
No one is saying cutting back on unnecessary medicine will be easy. There is a reason for every procedure doctors perform. The fact that the reasons are sometimes financial or legal (protecting against malpractice claims) makes them no less powerful. Few doctors have the training in statistics and trial design to understand what the science says about various therapies. And many honestly believe their patients are different from those in a study that found no benefit from some procedure. But if they're right about that, points out Baker of the spine society, it means there are no data that the procedure benefits those patients.
Consumers, too, are a powerful force for unnecessary medical care. Parents insist the ER do a CT scan on a child who bumped her head; runny-nose patients won't leave their internist without a prescription for antibiotics. "In a busy practice, it's sometimes easier to write the prescription than to talk the mom out of it," says pediatrician Beth Pletcher of the University of Medicine and Dentistry of New Jersey. And the heart patient who doesn't believe that pills could possibly be as effective as surgery? "Angioplasties, stents, and bypass have attained 'entitlement' status," notes Hadler.
Why do insurers pay for unnecessary care? Partly because they're battle-weary, having been successfully sued for refusing to cover, for instance, high-dose chemo plus bone-marrow transplants for breast cancer—which turned out to be not just useless but, for thousands of patients, deadly. "The abrasion that would result from even more intervention by health-care plans becomes problematic," says Joe Singer, vice president for medical affairs at HealthCore, a subsidiary of the insurance giant WellPoint. Translation: insurers have had it with trying to refuse coverage for useless procedures, since they can simply raise premiums—yours and mine—to cover the cost.
Perhaps, since so much useless care reflects financial incentives, financial disincentives might reduce it. In a paper last month in PLoS Medicine, R. Scott Braithwaite of the New York University School of Medicine and colleagues suggested that insurance cover 100 percent of effective diagnostic tests and treatments, but little to nothing for less effective ones. You really think you need an MRI for the back pain that started last week? It's on your nickel.
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