“I make my living off unnecessary procedures.”
So will be the rallying cry of some doctors once the true impact of comparative effectiveness research (CER) is felt.
Proponents of CER have been very careful not to associate its evidence-based findings with the coverage decisions of Medicare and other health insurers.
But let’s face it, that eventually has to happen. I see CER as the initial baby step to start the discussion on withholding treatment, since, after all, it’s the only real way to control health care costs.
Bob Wachter writes an excellent article on the history of comparative effectiveness in the United States, and how staunch the resistance was, and will be.
I’ll leave you with this money quote, accurately summarizing up the entire battle: “But let’s not be naïve about it ““ one person’s ‘cost-ineffective’ procedure may be a provider’s mortgage payment, a manufacturer’s stock-levitator, and a patient’s last hope for survival.”
The whole piece is well worth reading.
Related posts:
- Physician payment reform is the key to fixing the health care system
- Why doctors are doing so many unnecessary Pap smears
- Physician payment reform by capitation, will it work this time?
- We need comparative effectiveness research, or, I agree with Paul Krugman for the first time ever
- Health care and statistics
- A doctor in Cuba becomes a nurse in the United States
- Geriatricians on the decline, and why physician payment needs to be reformed
{ 15 comments }
"I see CER as the initial baby step to start the discussion on withholding treatment, since, after all, it's really the only real way to control health care costs."
As a patient, I call BS on that. I would LOVE it if my doctor could give me well-researched data on comparative effectiveness of different tests and treatments, compared to cost. I would personally take a med that costs $40/month over one that costs $400/month, even if the former is only 60% as effective.
In my experience, doctors often prescribe the newest (still in patent & hugely expensive) stuff over older stuff that is often just as effective, if not more so.
For example, I have ongoing treatment for neurogenic pain related to scarring in my abdominal cavity. New, fancy Cymbalta gave me terrible side-effects and cost so much! Old, dull amitriptyline was more effect for me and is out of patent so there are cheap generics available.
That's just one example; I have dozens.
Personally, the doctors I respect the most – and I've seen a heckuva lot – are the ones who try all the cheap, non-invasive, thoroughly studied stuff before they move on to the new, heavily promoted stuff. Copying the drug names on your notepads, pens, stethoscope etc onto a prescription pad does not earn my respect any more.
A doctor should aim to improve the patient's quality of life, and being saddled with big medical costs (and even co-pays can be big) does not make patients lives better. If something cheaper might be as or more effective, why wouldn't you want to know that?!?
Finally we as physicians will no longer be able to justify expensive treatments that offer no benefit, and sometimes harm our patients! I am thrilled that this is going through. The proceduralists will be unhappy, though, and will probably ignore the results as blithely as many PMDs ignore the results of the ALLHAT trial. Unfortunately, one of the tribulations (and joys as well!) of medicine is that care is very nuanced. It’s always possible to make an argument that this patient in front of you is different from the patients in that study because ____, so I don’t know how useful this will be in preventing unwarranted procedures. I am glad we’re at least on the right track.
Cosmetic medicine has faced these same ethical challenges for years. There’s never be a satisfactory resolution and neither the marketplace or the plastic surgeons / cosmetic derms seem to figure out what exactly to do with it. This may be s first step in the right direction.
I don’t know how much impact it will really have. There is an awful of service now that is clearly unwarranted and of no value but is still provided and charged for. If the bureaurocrats haven’t been able to stop the waste of primary care resources on family docs rounding on medically healthy patients on the psych ward every day for days or end, how will they ever muster up the guts to stop what is plausibly debateable?
Another reason “defensive medicine” is a canard.
Dr. Kevin, is it really “withholding treatment” if the treatment should not have been an option anyway? Expensive tests, procedures, surgeries, etc should not be done if it will not change the outcome of the patient significantly. For example, 1 in 3 women get a Cesarean Section in this country, supposedly to protect the infant. Yet, infant morbity has not decreased. Hopefully CER can help with decreasing unnessary expensive procedures, and maybe even lend some ammunition for tort reform.
RR
I extend my gratitude to doctors willing to acknowledge that, at times, it is their colleagues who are knowingly & strategically overtreating. Though I realize there are, conversely, patients who demand unwarrented procedures.
Acknowledging and speaking truth takes courage and is fraught with risk. Yet, these are the initial cornerstones to begin the struggle toward an ethical and balanced restructuring of a "diseased" system.
AS a victim of predatory surgery, I can safely say that it is impossible to accurately imagine what it is like to live with a combination of surgical-related disability, pain, and enormous loss of quality of life, along with the horror of discovering you have been strategically betrayed by a physician and her "team".
Thank-you to the ethical and patient-caring medical practitioners for speaking out.
“Expensive tests, procedures, surgeries, etc should not be done if it will not change the outcome of the patient significantly. “
Why not if the patient wants them and will pay for them?
” For example, 1 in 3 women get a Cesarean Section in this country, supposedly to protect the infant.”
According to who? Whose to say it isn’t done for convenience of either the patient or the doctor?
I know this is a serious and worthy topic, but the headline for this post reminded me of some fellow New Englanders…
It’s Saturday morning and you’re listening to NPR…
Have a question for (Drs) Quick and Quack, the Tap-It Brothers? Call 1-888-MED-TALK.
Tom: Hello and welcome to MedTalk. Caller: Hi, this is Tammy from Somerville. Ray: Is that Tammi with an i, or Tammy with a y?
Caller: With a y.
Tom: How can we help you, Tammy? Caller: Well, I saw a cosmetic surgeon today, and he suggested I get a heart bypass along with my… Ray: Let me guess – you’re having a little problem with your front end? Caller: Yeah, you could say that! I don’t get the bypass thing though. Tom: Sounds like that guy is behind on his boat payments to me! (laughs) Ray: (laughs) Yeah, you might want to give that guy a bypass yourself – try a heart specialist and let us know how it goes. We’ll talk to you later on Stump the Chumps. Caller: Thanks guys – I love your show! Tom: Thanks for calling, Tammy. Now, don’t prescribe like my brother! Ray: Don’t prescribe like *my* brother!
“Why not if the patient wants them and will pay for them?”
But this is what is so key! How many patients that you know would pay out of pocket for something that a physician told them wasn’t medically necessary (putting today’s malpractice environment aside)? They’re not going to! Who has an extra $12,000 lying around? (number is an estimate) A few people do, but not many. People think because they pay for insurance they should get whatever procedures they want. I guess you could make that argument, but that’s part of what got us in this mess in the first place. Even though it’s you paying for your insurance, it’s all of us paying for the increased cost of medical care.
“Even though it’s you paying for your insurance, it’s all of us paying for the increased cost of medical care.”
That doesn’t make sense because it assumes the insurers routinely approve payment on unnecessary procedures. Do they?
But you have a good point in that the payment model the physicians chose is a large part of the problem.
“Why not if the patient wants them and will pay for them?”
The problem is most patients don’t pay for all those expensive tests and procedures. Employers pay the ever increasing health insurance premiums, while the patient pays a $30 copay and feels like they are entitled to thousands of dollars worth of tests or procedures. Which leads to higher overall health care costs and higher premiums. Eventually if the patient looses their job or the employer can’t afford the increasing premiums anymore, then the patient has to pay some or all of the premium themselves and feel even more entitled to those tests and procedures because “I am paying for it” This leads to even more increased health care costs and no improvement in outcomes.
I haven’t switched my patients to diuretics for many reasons. I’m not ignoring allhat. But if amlodipine is working, why switch? And diuretics make you piss. sometimes a lot, and some patients dont like having to piss all the time. And it causes diabetes in 12% of patients. And has other metabolic effects. And the NEw York Times may not be the place to start realizing that the study wasn’t powered to look at many of the erroneous conclusions made from that study.
Please, no one is ignoring ALLHAT. Its all anyone freaking talked about for a year. But leave the discussions to people who actually practice medicine.
“That doesn’t make sense because it assumes the insurers routinely approve payment on unnecessary procedures. Do they?”
Trust me, they do. All the time. Because you can always make a believable argument that something is necessary. I see people undergo unnecessary studies every day, some of which are potentially risky. If you put the same scenario in front of 10 physicians, 9 might say it’s unnecessary, but if the 10th says it is, the insurance will pay. Medicine is not cookie-cutter; everyone has his/her own medical conditions, symptoms, or family history that makes a study justifiable, even though it may not truly be needed.
“Because you can always make a believable argument that something is necessary.”
So then the physician is lying about its necessity?
“Employers pay the ever increasing health insurance premiums, while the patient pays a $30 copay and feels like they are entitled to thousands of dollars worth of tests or procedures.”
That assumes the money wouldn’t go to the employee if the employer weren’t negotiating with the insurer on his/her behalf. It’s still the employee’s money, or at least a part of their salary package. It IS their money, it’s not their fault the provider cut a deal with the insurer to provide services at a particular cost. No one made the provider do that.
“Which leads to higher overall health care costs and higher premiums.”
Too simply. Lots of things lead to high premiums, from the stock market to the real estate market to the overall health of Americans. It’s not simply “order more tests, everyone pays more money”.
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