What exactly is unnecessary care?

It’s become one of those trendy phrases, “unnecessary care.” When you hear it on television or talkshow radio it’s usually said with a sneer. Indeed, the speakers almost spit the phrase out — “unnecessary care” — like it tastes bad.  It’s almost always accompanied by “fraud and abuse,” or a not so subtle accusation that some doctor is profiting off this unnecessary care at the expense of some poor patient. But is this true? Is this always the case? Are there no longer any circumstances whatsoever where the doctor really does know best?

I’m an ophthalmologist, an eye surgeon.  Every single day in the office I see several patients who have enormous cataracts which have dramatically affected their vision, and yet they are not only totally unaware of this decrease, they are militant in their rejection of surgery to improve their vision. Some of them have vision which has decreased to a point where, not only would they fail their drivers license test, they are nothing short of a menace to society behind the wheel. Because cataract surgery is an elective procedure, the patient gets to choose whether or  not to proceed with surgery. In other words, operating on a patient with a cataract who does not feel he has a problem would be “unnecessary care.”

The opposite version of this happens every day, too. In about 25 states there are strict, numerical guidelines that insurance companies (including Medicare) used to determine whether or not cataract surgery is medically necessary. Not a day goes by when I don’t see a patient who is bitterly unhappy with her vision, and yet her measured visual acuity is better than the threshold for medical necessity. Despite the fact that this patient feels handicapped by decreased vision caused by a cataract, operating on her is considered unnecessary care.

It kinda tricky. Sort of a damned if you do, damned if you don’t thing. I know it seems like a rather fine distinction, but cataract surgery is actually a big deal when it comes to the economics of medicine in the United States. Did you know that there are almost 3,000,000 cataract surgeries performed every year in the United States? Could some of these surgeries have been unnecessary? I dunno. I’m really struggling with the definition of necessary, frankly. Is cataract surgery in my two patients unnecessary? Says who?

You can achieve the same relative mortality rates for atrial fibrillation with either a cardiac ablation, or a cocktail of medications. Maybe you are medicine–free with the ablation, and therefore free of not only the yoke of your daily medicine schedule and side effects, but also the considerable burden of navigating your health insurance-approved medication list. The ablation might be 10 times the cost of the medicines, but does that make it unnecessary? Too much? Says who?

So how do these two cataract patient scenarios play out? Well, the very unhappy patient with a cataract of any size whose vision does not reach that threshold level of medical necessity always chooses to wait until her insurance will pay for the cataract surgery. Always, whether she is a retired schoolteacher or a wealthy heiress worth tens of millions of dollars. She leaves the office unhappy, frustrated, and frightened. She cannot enjoy her daily activities because she cannot see well enough, and she is frightened by the prospect of normal activities like driving.

The other patient? Well, this patient typically has a monstrous cataract, so brown and cloudy it’s like looking through beef broth, or even beef gravy. This patient gets angry, too, but he is angry at me. He’s angry and offended that I would have the audacity to suggest that his vision is poor, too poor to drive, for example. He doesn’t understand what 20/50, or 20/80, or 20/100 vision means, and frankly he doesn’t really care. He’s got a drivers license, dammit, and he’s legal to drive. These visits almost always end something like this:

Me: “What kind of car do you drive?”

Patient: “A crown Vic.”

Me: “What color is your Crown Vic?”

Patient:” White. Why?”

Me: “Because my wife and kids are driving on the same roads as you, and I’m going to tell them to stop and pull over every time they see a white Crown Victoria.”

I say that’s necessary care.

Darrell White is an ophthalmologist who blogs at Random Thoughts from a Restless Mind.

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  • Anonymous

    Another example of the FAIL that is Third Party Payor …

  • Anonymous

    It’s long been known  that  the entereprise of US Organized Medicine contributes less that 10% to overall health outcomes. Health habits and Public Health are vastly more important. So we have all been duped by an enterprise that we mostly don’t need.  Ergo most medical care in that broadest sense in unnecssary.

  • Anonymous

    I thought dr’s were required to tell the dmv if someone should not be driving with a certain medical condition.  Or are there restrictions to what they can report to the dmv? Or am I thinking of California law?  So if there are restrictions, shouldn’t the law be changed.  For example the person with cataracts who does not fix them, should have to take a vision test at the dmv on regular basis and not wait to the license comes up for renewal.

    • http://twitter.com/DarrellWhite Darrell White

      Sue, while there may be a law in CA as far as I know there is no law that trumps HIPPA and doctor/patient confidentiality in OH. 

      • Anonymous

        From an article in the NY Times

        “Dr. Reisman studied up on the issue in part by using the A.M.A. guidebook. That is where she learned that only six states — California, Delaware, New Jersey, Nevada, Oregon and Pennsylvania — have mandatory reporting requirements for doctors. Other states, Connecticut among them, do not require a doctor to report a physically or cognitively impaired driver but permit doctors to express their concerns if they fear harm to a patient or the public”

        Seems like you should advocate for a change in the law in your state. My aunt lives part time in Ct and part time in FL.  She says it is much safer to drive in CT.  I now understand why– they have a law that permits dr’s to ensure the public safety.

        My dad’s neurologist said he would always tell us when my dad’s tests showed he could not drive.  The time came; the dr wrote to the dmv; they requested my dad come in for a test; he handed the keys to my sister  who at that time was driving him 99% of the places he needed to go.  He was only driving to his “discussion” group.  He called someone in the group and got a ride.  My admiration for my dad is great.

        I’m glad I live in California.

        Sue Feinstein

  • http://www.facebook.com/profile.php?id=100001356842723 Henry Ehrlich

    Have you ever discussed this with your fellow ophthalmologist Rand Paul?  He seems to think he has all the answers.

  • Anonymous

    I think there are clear examples of unnecessary care.
    I was reading a report on the excess in the American system with terminally ill, elderly women being put through pap testing and mammograms and other horrifying things.
    I think defensive medicine and profits explain this bizarre conduct…which IMO, amounts to abuse.
    I know the over-everything attitude that exists in the States just ends up worrying and harming lots of people and generates huge profits for doctors and others. (and perhaps gives them peace of mind from legal action)
    Give me evidence based care any day….but that means doing your own research and making your views clear to the doctor – taking responsibility for your informed decisions.

    Cataract surgery is different – if it’s affecting your quality of life, then get it fixed. In the Aussie system you might have to wait for a public bed, but with private insurance, you’d get it sorted out very quickly. If people don’t want the surgery and are prepared to live with the issue, then that’s their right.

    The driving thing is a difficult problem though – I think we all need to take some responsibility there – keep an eye on our relatives and friends. (especially as they age or when they’re unwell) My father was unable to drive for a year leading up to his death and he was bitterly unhappy – he saw it as the end of his independence. We had to put a steering wheel lock on the car to prevent him from driving…that was a clear case however of someone who definitely shouldn’t be on the road for his own and others safety – it’s the grey area that’s very difficult. We have to respect the individual and protect the public at the same time – let’s hope most patients understand they have an issue and get it fixed before something tragic occurs…
    An aunt had a scare on the roads – just didn’t see a cyclist and realized she had lost some peripheral vision – some act on the wake-up call and do so before their problem leads to tragedy, others are not so lucky.
    I’d hate to end up harming someone simply because I refused to accept I needed cataract surgery – you have to live with that regret and guilt for the rest of your life.

  • http://www.facebook.com/jonathan.marcus.ca Jonathan Marcus

    I practice medicine in Canada.  If someone has a medical condition that makes driving potentially unsafe, I have a legal obligation to report them to the Ministry of Transportation, who usually suspends their license until the medical condition is taken care of.  This law trumps privacy laws. If HIPPA trumps this in the USA, this needs to be dealt with. A car is a lethal weapon in the wrong hands and is possibly more dangerous than letting someone demented walk around with a loaded gun.

    • Anonymous

      Mandatory reporting in the same deal in the WA state, Jonathan. 

  • Hemang Shah

    in second scenario where patient is refusing to get surgery and his action have the potential of injury to self and others, can u not inform the DMV?

    • http://twitter.com/DarrellWhite Darrell White

      Nope. Not in Ohio. 

  • Anonymous

    Removing large cataracts is necessary care.  Next case.

  • Anonymous

    Sadly, the law is wrong this time. Doctors should be required, not just allowed, to report people who could cause harm just like doctors are required to report signs of abuse or neglect to children. People lose their licenses for repeat DUIs so why not when they lose their sight? Being sober won’t do you much good if you can’t see.

    I would also like to talk about what constitutes unnecessary care. Most care (consults, tests or procedures) is necessary. Situations where care is deemed unnecessary are very specific:

    - Like elizabeth52 mentioned, tests like Pap smears in people over 70-75. Life expectancy in the US is about 77 years. Unless you cancer is really aggressive, you could still live 5+ years without going through cancer treatments (chemo, radiation). Spend time with your family instead.

    -When the symptom doesn’t affect your life. I have a bump in one of my fingers because a medical student or resident really screwed up some stitches. A doctor said I could get surgery to “correct” it. What for? I never notice it anyway.

    -When doctors refuse to listen how chronic sufferers commonly deal with their condition. This one is personal because it recently happened to me. I commonly have sinus infections which require prescription meds to treat. The symptoms always look the same: sneezing, runny nose, light to mederate wheezing. A doctor wanted to give me a chest x-ray and maybe leave me overnight for observation. I politely refused and was fine two days later. THAT would have been incredibly unnecessary.

    Anything else is fair game . By the way, the media should know that just because a test was negative it doesn’t mean it was a waste of resources.

  • Anonymous

    Interesting perspective, Dr. W.  Thank you for this. There are a couple distinctly separate issues here: first, care that the patient (like your Crown Vic driver) believes to be unnecessary, and second, care that the patient becomes convinced IS necessary – but is actually not. Only the latter is what’s being sneeringly referred to as “fraud and abuse”. (The former, as our Canadian doc points out here, may require legislative change in this particular case, but still wouldn’t necessarily ever convince a driver in denial that his eyes need treatment).

    As a heart attack survivor, my own concern is far more focused on issues like the current stent-happy cardiologists who have been accused, investigated, fired, had their license to practice medicine revoked, or in some cases, convicted of health care fraud for implanting medically unnecessary coronary stents. According to a study of almost 500,000 cases reported in JAMA in July, for example, only half of procedures that used angioplasty/stents in non-emergency cases were deemed “appropriate”.

    None of this news does anything to help allay suspicions in both professionals and patients alike that something is very wrong in the cath lab. More on this at: http://ethicalnag.org/2011/06/04/unnecessary-stents/

  • http://pulse.yahoo.com/_EQM4S4S2BWEQLSXQ2VZNYN6B2I odysseus6996

    Most “unnecessary care” in the end is consumer  and managed care driven …the demand for anti-biotic by intractable parents, “I want the MRI for my broken leg not the x-y ray…I need all these blood tests,(I read about it in the newspaper) I’ll sue if anything happens.” As most professionals know that just about anything can happen. Though it might be flagrant disregard of post-op instructions etc., guess who is swinging in the breeze at the end of the day.  The development of technology and all the new toys are a factor. We have them, therefore we use them, whether we need to or not.  Then there is the grey area of what is defined by managed care as unnecessary care and what is in fact necessary care. Neither of these outlooks serves anyone well….well maybe the managed care company.   Society is ill served by the development of resistant bugs and high health care costs, as all these tests do cost money. The price of them is debatable. They will keep being used as managed care keeps paying for them. This begs the question why managed care approves unnecessary procedures but denies necessary one.
     What is defined as necessary is more and more defined by bureaucrats in managed care companies with the help of physicians that have a vested interest in the definition of “necessary”. The treating physician may say it is necessary but the medical director one-thousand miles away says it isn’t as it doesn’t fit the “guidelines” (which are not guidelines but parameters of care rationing). They may approve as they have some percentage of ownership in the the testing companies but let’s not go there. Sometimes the definition of unnecessary and necessary is just a mystery of life.

  • Thaddeus Pope

    In Pennsylvania conditions that could affect safe driving are mandatory reports to DMV.  

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