What makes doctors "re-treat" patients?
Medicine is not for the future
Andrey Ukrainsky, XX2 century
You can often hear about unnecessary treatment and unnecessary diagnostic procedures. Friends and relatives talk about them, the media periodically write about them. Someone was prescribed optional tests, and somewhere an entire clinic was caught in copious "overtreatment" of patients. The information is usually scattered, causing concern rather than explaining the problem.
Below we will try to at least partially summarize the data on unjustified medical interventions, to indicate their nature. The article is based on foreign studies, since this phenomenon is not studied here. The similarity of the problems faced in countries with significantly different health systems (examples from the USA, Canada, Australia are given below) emphasizes that the examples given are quite universal, their national specificity is insignificant.
How is treatment distinguished from "overtreatment"?
Unnecessary medical care is periodically referred to in the literature as "overtreatment", although this concept often includes non-required diagnostics. This problem has long been recognized as serious, even the modern edition of the Hippocratic Oath, dating from 1964, contains a warning against it [1].
One of the pioneers of the study of the issue was John Wennberg, who began research on the instructions of the government of Lyndon Johnson. In his opinion, treatment and diagnosis caused not by clinical necessity, but by other factors are considered unjustified [2]. Other definitions remind of the importance of the cost of services in the analysis: ""Overtreatment" – medical services provided in a larger volume or at a cost higher than reasonable" [3]. In 2009, the Annals of Internal Medicine noted that unnecessary medical care "does not provide tangible benefits to the patient." The authors were based on the results of a 2003 study that showed that the health of patients in areas with high medical expenses under the MediCare program is no better than in regions with low [4].
Protective medicine
According to a recent survey, 85% of doctors consider the desire of a doctor to protect himself legally to be an important reason for "overtreatment" and high expenses [6]. That is, unnecessary procedures are carried out not because it is necessary, but because it is supposed to be according to the protocol. However, the well-known surgeon and publicist Atul Gawande and co-authors showed that in 2008 spending on protective medicine did not exceed 2.4% of the US medical budget [5]. Considering that all unnecessary medical expenses are estimated at 30-40 cents per 1 dollar [7], the main problems should be looked for elsewhere.
Nothing personal, it's just…
More than 70% of doctors believe that colleagues often perform unnecessary procedures when they make a profit from them, but only 9.2% of respondents admitted that they practice it [6]. The most important root of abuse is the fee-for-service method that dominates today, in which doctors or medical institutions receive payment for each service rendered (and not for the number of patients, for example). This happens both at the expense of private and public health insurance [3].
John Wannberg considered this phenomenon from the point of view of the economic law of supply and demand. In theory, when an excessive supply appears, the price of the service should decrease. In healthcare, especially in government programs, prices are relatively stable. As a result, the excessive supply of medical services does not reduce the price, which increases the likelihood of abuse [2].
Atul Gawande in 2009 published an article with one of the examples of such abuses in McAllen (Texas, USA) [8]. In this city of reimbursation Medicare was twice as high as the national average. At the same time, back in 1992, this place was no different from other regions. Having studied the situation in detail, the author ruled out the possibility of particularly poor health of the city's population and criminal negligence of doctors. McAllen turned out to be a textbook case of abuse of medical services by specialists. According to Gawande's findings, local doctors have developed a business approach to practice, which threatens to become mainstream healthcare.
A typical and egregious example of the abuse of diagnostic procedures is medical imaging: X-ray examination, computed tomography and magnetic resonance imaging. The Canadian Association of Radiologists reported that in 2009 about 30% of such procedures were not necessary from a clinical point of view [9]. This is a consequence of various factors: patient requirements, hospital routine and technocracy, protective medicine. But the most important point is that many doctors, not radiologists, make a profit by being co-owners of medical practices and radiological equipment. They refer patients "to themselves" (self-referral), that is, to institutions that will bring profit to them or their friends. The growth in the use of medical imaging in the United States is associated with this phenomenon. In 2004, its excessive use cost the US healthcare 16 billion dollars [10].
According to an Australian study, the commercialization of reproductive medicine has led to the fact that women are prescribed additional cycles of in vitro fertilization (IVF) even in cases where success cannot be expected. IVF is also performed for couples who can be helped with less invasive methods. State insurance covers each IVF cycle, but only partially, that is, there is a co-payment. Beneficiaries do not take into account that the procedure is not indifferent to health (hormonal stimulation of superovulation) and carries unjustified expectations every time [20].
Invasive cardiological procedures account for a considerable share of excess medical care. Thus, it is estimated that one of the eight coronary stents (a frame structure that slows down the narrowing of the coronary arteries, ≈$20,000 per procedure) they are placed without sufficient indications. In St. Joseph Hospital (Saint Joseph Hospital, Maryland) in 2011 there was a major scandal when hundreds of cases of installing stents that were not required by patients were discovered [11]. At the Redding Medical Center (since 2004 – Shasta Regional Medical Center) in 2002, a patient stated that he had undergone non-required coronary artery bypass grafting. After the FBI investigation, the hospital paid millions of dollars in fines and compensations to hundreds of patients [12].
Here it is appropriate to recall the Nobel laureate Bernard Lown, a famous cardiologist, one of the fathers of the modern defibrillator, a well-known fighter against abuse in medicine. With his collaborators, Laun conducted studies showing that in many cases conservative vascular treatment gives better results than surgery. Here is a characteristic quote from his interview:
"When I see a patient, I get 60-70 dollars an hour. But if I run a tube into his heart to clear the vessels, I get 2-3 thousand dollars for a simple operation. In other words, society pays many times higher for the use of technology than the skill of interpersonal communication. As a result, American doctors have forgotten the art of healing" [13].
Consume
Direct advertising of medical products and services stimulate people to consume. About 60% of doctors say that under its influence, patients require unnecessary treatment [6]. For many doctors, in this case, it is easier to follow the lead of the person asking than to explain why this is not required or even harmful: 44% of patients receive the required [14]. In Florida, a 10% increase in the share of medical advertising led to a 5% increase in prescribing [15]. Large pharmaceutical companies spend more money not on drug development, but on advertising [16].
Doctors often complain about this circumstance. At the same time, they massively take remuneration from pharmaceutical companies, which affects their prescriptions [21], advertise medicines in social networks, hiding material interest [17].
Independence from the patient
In some cases, the method of treatment should depend on the preferences of patients. For example, in the treatment of uterine fibroids, surgery or hormonal treatment may be chosen. Wannberg notes that programs that help patients make choices reduce the amount of unnecessary treatment. However, in real life, patients do not have a proper understanding of their condition, and doctors do not spend time on their training. Thus, the choice usually remains not for the consumer of the medical service, but for its provider. And today, healthcare systems encourage the choice towards more expensive and not always justified procedures [2].
Even premium health insurance plans negatively affect the choice of patients. A Canadian study showed that insurance companies and health care providers only profit from such offers. They can encourage people with chronic diseases to turn to more expensive treatments that often do not improve the outcome of the disease. The reason is also poor patient awareness. Faced with uncertainty, they ask the doctor to suggest the best method and help them choose an insurance plan.
"People don't arrange car accidents and don't burn down their homes just because they have higher-level insurance. But they clearly tend to choose more expensive treatment if medical insurance can cover it," the authors draw parallels [18].
"Undertreatment" – the reverse side of "overtreatment"
Against the background of the above, it looks quite unexpected that "overtreatment" goes side by side with "undertreatment". While services that bring good profits are abused, people do not receive simple effective help. This applies to procedures, the use of which significantly improves health and quality of life. Usually these are simple and cheap interventions, for example, the use of beta blockers after a myocardial infarction, regular eye examination in diabetes mellitus, some types of vaccination. This is another touch to the picture of "re-healing" people with the help of not the most necessary methods.
The fight against "overtreatment" is a separate big topic, which we can only mention in this article. The greatest scope was given to "application management", which focuses exclusively on reducing the costs of the insurance company. A huge staff of specialists is looking for reasons for refusing to pay for medical services, as a result, people simply do not receive help. This phenomenon is well illustrated by Michael Moore's film "Zdravozakhoronenie" (Sicko). Another method dealing exclusively with the material side is co–payment. This is a form of medical insurance, when the patient has to partially pay out of pocket, since the insurance does not fully cover the treatment. Initiatives that focus on clinical and ethical aspects have not received sufficient scope for today. For example, Choosing wisely, a large-scale educational campaign in the field of healthcare in In the United States, headed by the American Board of Internal Medicine (ABIM), after five years of existence, has yielded extremely modest results [19]. Thus, the elimination of these abuses in the healthcare sector is a matter of a bright future.
Literature
1. In the text, the warning sounds like "...avoiding those twin traps of over-treatment and therapeutic nihilism".
2. Michael T. McCue, Clamping down on variation – Managed Healthcare Executive, February 01, 2003
3. Ezekiel J. Emanuel, Victor R. Fuchs (2008). The perfect storm of overutilization (PDF). The Journal of the American Medical Association. 299 (23): 2789–91.
4. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL (February 2003). The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann. Intern. Med. 138: 288–98.
5. Steven A. Schroeder (April 2011). Personal reflections on the high cost of American medical care: Many causes but few politically sustainable solutions. Archives of Internal Medicine. 171 (8): 722–727.
6. Lyu H, Xu T, Brotman D, Mayer-Blackwell B, Cooper M, Daniel M, et al. (2017) Overtreatment in the United States. PLoS ONE 12(9): e0181970.
7. Lawrence, David (2005). Building a Better Delivery System: A New Engineering/Health Care Partnership – Bridging the Quality Chasm. Washington, DC: National Academy of Sciences. p. 99.
8. Atul Gawande. The Cost Conundrum – What a Texas town can teach us about health care. The New Yorker. (June 1, 2009).
9. Dawson H. Family Doctors and Lower Diagnostic Imaging Costs: How Do We Get There from Here? Healthcare Policy. 2011;6(4):32-34.
10. David C. Levin & Vijay M. Rao (March 2004). Turf wars in radiology: the overutilization of imaging resulting from self-referral. JACR. 1 (3): 169–172.
11. Meredith Cohn (July 29, 2011). St. Joseph Medical Center’s CEO resigns. The Baltimore Sun.
12. Gilbert M. Gaul (July 25, 2005). At California Hospital, Red Flags and an FBI Raid. The Washington Post.
13. It's time to treat. Results, 600 (10.12.2007)
14. McKinlay, John B.; Trachtenberg, Felicia; Marceau, Lisa D.; Katz, Jeffrey N.; Fischer, Michael A. (April 2014). Effects of patient medication requests on physician prescribing behavior: results of a factorial experiment. Medical Care. 52 (4): 294–299.
15. Cause and Effect: Do Prescription Drug Ads Really Work? Knowledge@Wharton.
16. Anderson, Richard (2014-11-06). Pharmaceutical industry gets high on fat profits. BBC News. Retrieved 2017-08-12.
17. Conflicts of interest in Twitter. Kaestner, Victoria et al. The Lancet Haematology, Volume 4, Issue 9, e408 – e409.
18. Nitin Mehta, Jian Ni, Kannan Srinivasan, Baohong Sun. A Dynamic Model of Health Insurance Choices and Health Care Consumption. Marketing Science. Volume 36, Issue 3.
19. ‘Choosing Wisely’ movement: Off to a good start, but change needed for continued success. Michigan Medicine, 2017.
20. Conflicts of interest in Australia’s IVF industry: an empirical analysis and call for action. Brette Blakely, Jane Williams, Christopher Mayes, Ian Kerridge & Wendy Lipworth Human Fertility, Published online: 01 Nov 2017
21. Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia. Susan F. Wood, Joanna Podrasky, Meghan A. McMonagle, Janani Raveendran, Tyler Bysshe, Alycia Hogenmiller, Adriane Fugh-Berman, Published: October 25, 2017.
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