The Economics...And The Ethics...Of "Just Being Sure" And "Doing Something"...

The past few weeks have been a little intense for our family.

Our brilliant, beautiful, athletic 19-year-old daughter found a lump where there certainly shouldn't have been one and, naturally, promptly freaked out.

She's the scientific type, so we started with a little literature research, and found that for women her age, 99% of those lumps are nothing significant to worry about. But there's still that one percent.

So over four weeks, she went from her doctor to a specialist to a surgeon, and from X-ray to ultrasound to MRI. At every step along the way, she would be assured by the physician that the likelihood that the lump was anything to worry about was very small. Still, we went up the ladder of protocol. And after three physicians had seen her, and a radiologist reviewed all her tests, we found...nothing to be worried about.

So our daughter had a little scare...but no harm done.

Her EOB's for her various tests have just finished coming back. The assurance of "just making sure" set our health plan back about $10,000. I think we paid about $150 out of pocket.

It goes without saying in the health care racket that "unnecessary health care costs" are generally those incurred by the OTHER guy's daughter. Still, the episode left me thinking:

If we'd had no health insurance coverage, how far would our providers have gone "just to make sure?"

If we'd had a high-deductible health plan, with, say, a $6000 family deductible, how much would WE have been able to spend out of pocket, "just to be sure?" There's ample evidence indicating that subscribers to HDHP's tend to put off potentially costly medical procedures because of the out-of-pocket costs involved. Would we have just assured our daughter that "it's probably nothing," and urged her to be watchful in case there was any change?

It's cases like this which re-inforce to me the ludicrousness of the prevailing notion (among some circles) that "empowering individuals" is somehow the key to reducing health care costs. A scared 19-year-old kid with a mysterious lump is not inclined to be a discriminating shopper...even if there were reliable efficacy/cost/outcomes data out there...which, of course, there isn't.

And it also caused me to think about how many times a day similar scenarios play out. How many dollars are incurred on procedures which are initiated "just to be sure?" How many of these procedures are necessary? And how many cause more anxiety or lead to cascading medical interventions which make things worse?

Recent news contained a few answers which ought to give us pause:

Last week the U.S. Preventive Care Task Force, which raised a firestorm in 2009 when it questioned the efficacy of annual mammograms for healthy women, recommended that routine PSA screening should be restricted, especially for younger men with no signs or history of disease. A member of the panel said that, especially in younger men, “The harms studies showed that significant numbers of men — on the order of 20 to 30 percent — have very significant harms," in the form of anxiety, unnecessary surgery, or other procedures;

Researchers at Mt. Sinai Medical Center in New York conducted a study which concluded that more than $6.7 billion in unnecessary tests and procedures were conducted at the primary care level last year, of which an astonishing 86% were attributable to the prescription of name-brand statin drugs to treat high cholesterol.

"Led by Minal Kale, MD, a postdoctoral fellow in the Division of Internal Medicine in the Department of Medicine at Mount Sinai School of Medicine, the research team reviewed findings from a study published in the May 2011 issue of Archives of Internal Medicine, which identified the top five most overused clinical activities in each of three primary care specialties: pediatrics, internal medicine, and family medicine. With this information, they performed a cross-sectional analysis of separate data that were pulled from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. They found more than $6.7 billion was spent in excess healthcare spending in the primary care setting in 2009. Eighty-six percent, or more than $5.8 billion of the unnecessary spending, resulted from the prescribing of brand-name statins rather than generic versions.

“Our analysis shows astronomical costs associated with prescribing of brand name statins when effective, generic alternatives were available. Efforts to encourage prescribing of generics clearly have not gone far enough,” said Dr. Kale. “Additionally, millions are spent on unnecessary blood work, scans, and antibiotic prescriptions. Significant efforts to reduce this spending are required in order to stem these exorbitant activities.”

And to raise the stakes further, an article in The Lancet rocked the establishment with a review of 1.8 million Medicare recipients over 65 who died in 2008. The study found that a third of those beneficiaries underwent surgery in the year before their death. One out of eight had had surgery in the month before their death, and one out of ten had undergone surgery in the week before their death.

While this makes sense on the surface...older people with health problems do undergo surgery, and many will die afterward...the study concluded that much of the surgery performed did not affect the patient's outcome.

More disturbingly, even physicians interviewed for the study suggested that the surgery wasn't necessary, but was instead performed to appease patients and their families, as an alternative to having "the discussion" about how the patient wished to spend what remained of his/her life. Surgeons, especially, often have the temptation to "do something" to help a patient, even if the procedure will have little or no clinical value.

And finally,The Agency For Health Care Research And Quality released numbers which indicated that treatment for septicemia, a blood infection featuring bacteria such as e coli and MRSA, was the single most expensive cost to U. S. hospitals in 2009, with a total cost of $15.4 billion. Septicemia cases, which are almost always the result of hospitalizations, increased from 337,000 in 2000 to 836,000 in 2009, making septicemia the sixth most common principal reason for hospitalization in 2009. Death rates from septicemia were also estimated at 16% in 2009...eight times higher than death rates from other causes...which demonstrates once again that, given rates of hospital-borne infections (always underreported by hospitals), hospitals are crummy places for sick people.

And besides, Medicare pays.

There are questions to be raised from these and all such studies; after all, when you don't agree with the outcome of a study, it pays to question the methodology. And all these studies admit variations in practice patterns (Medicare patients were three times as likely to have surgery in Muncie, Indiana than in Honolulu), but the facts remain:

Spending on tests and medical procedures, including surgery which, at the very least, do little clinical good and often can cause needless harm, add billions and billions and billions of dollars to American health care spending;

Among hospitals and physicians, especially as it relates to Medicare, there is a lot of conflicting pressure between clinical efficacy and the need to generate revenue;

Medicare is essentially a blank check;

Health plans aren't doing their jobs on behalf of their customers as a population;

And as the pressures on health expenditures rise, political and clinical leaders are going to have to confront the reality of "blank check" medicine. And because at least half of all health care expenditures are incurred by people in their last month of life, we're going to have to get over all this nonsense about "death panels" and begin an honest discussion of how we place limits on medical and surgical interventions at the end of life.

If cost containment were really a priority, these discussions would be happening now. But as long as hospitals, especially, are in the business of generating revenue from needless human suffering, those conversations are going to have to start somewhere else.