The U.S. spends nearly $3 trillion a year on health care, significantly more than any other nation.
In fact, America’s annual health care spending is greater than the total gross domestic product (GDP) of every other country except China, Germany and Japan.
Yet our measurable health outcomes — from infant mortality to life expectancy — aren’t any better than nations spending much less.
I’ve written about this paradox before, pointing to a few factors that drive up health care costs. They include the perverse financial incentives of health care’s fee-for-service payment model, the unjustifiably higher costs of devices and drugs in the U.S. and our systematic investment in specialists over primary care physicians.
But these are just a few of the reasons.
In the coming weeks, I will write about four common myths that contribute in powerful ways to our high health care costs and lagging clinical outcomes. Each represents a major opportunity to improve quality, personalize medical care and make health care more affordable.
Let’s kick things off with myth #1: More visits, tests and procedures lead to better health.
It seems logical that doing more would lead to better clinical outcomes. Sometimes that’s true. But more often than not, that assumption is far from factual.
Here are three common clinical practices that reveal the surprising truth behind this myth:
1. Annual physical exams. Beginning in the 1940s, the annual comprehensive physical examination was created as a “routine check-up” for patients with no visible symptoms or specific complaints.
These once-a-year exams have been standard medical practice ever since. In these face-to-face visits, the doctor asks about the patient’s health history, checks vital signs, listens to the heart and lungs, and examines the head and body.
The intent is to help physicians identify medical problems early and treat them immediately. Many swear by them. In fact, these routine check-ups are among the most common reasons adults see a physician. They account for nearly $8 billion in annual health care spending alone.
But, in practice, the doctor almost never finds anything wrong when there are no symptoms present.
As a result, many professional groups and researchers have concluded the annual physical exam adds little or no value. What’s more, experts have uncovered a number of serious drawbacks to such yearly visits. Studies show they can lead to false positive results, triggering a series of unnecessary tests. Or worse, they can give patients false assurance that everything’s OK, leading them to ignore new symptoms later on.
While a physical exam for a symptomless patient may be a waste of time and money, there’s a great deal of value in periodic laboratory testing — for blood lipids and glucose, for example – based on a person’s age and sex.
And for patients with a specific health problem such as diabetes, ongoing in-person and lab evaluations are essential. However, for patients without a specific medical condition, physicians could order the recommended screening studies electronically and discuss each patient’s results by phone without an in-person visit.
Why don’t they? Most insurance carriers refuse to pay the doctor for this service unless it is part of an office visit.
The result or more office visits and thus more health care spending: zero measured improvements in patient health.
2. Prostate cancer screenings. Physicians conduct the prostate-specific antigen (PSA) screening to detect prostate cancer early and allow for early treatment. It is commonly assumed that early detection saves lives.
But two large clinical trials show no overall benefit from mass screening for prostate cancer. And the United States Preventive Services Task Force recommends against PSA-based screening, finding that for every 1,000 men screened, at most 1 man avoids prostate cancer.
Certainly, the thought of saving one human life is reason enough to give such an exam, right? Not so fast. Of that same 1,000-man sample, up to 120 men walk away with e a false-positive test result – wrongly indicating the presence of cancer.
A positive PSA test is typically followed by a biopsy to confirm the presence of cancer with a major risk of a complication.
And even when the set of tests rightly identifies a patient with cancer, rarely does the cancer lead to health problems.
Unfortunately, in most cases, doctors can’t differentiate between cancer that will become harmful and cancer that won’t. So, when tests suggest the presence of prostate cancer, most men pursue treatment.
The most common treatment options are surgery, radiation therapy, hormone therapy and chemotherapy. Each option exposes men to possible surgical complications, along with erectile dysfunction and incontinence.
All of this might be worth it if the outcome was an increased cure rate. But that has never been shown. Instead, the impact on survival and life expectancy remains unchanged based on the largest research studies.
Once again, more is not better.
3. Surgery for patients with back pain. There are numerous treatment options for back pain: medication, physical therapy and surgery.
Surgery is by far the most risky and costly option. And, strangely, it’s a lot more popular in some parts of the world than others.
The rate of back surgery in the U.S. is five times higher than in the UK. And certain counties in the state of Washington boast 15 times more back surgeries than in neighboring counties.
This raises the obvious question: Are higher rates of back surgery tied to higher incidences of back pain or other medical problems?
There’s no evidence to indicate there is. So then, perhaps these locations with higher rates of back surgery are able to achieve superior clinical outcomes? Wrong again.
Studies have shown little difference in long-term outcomes for patients who undergo back surgery compared to those who select non-surgical treatment.
There are a few situations where surgery is essential and beneficial, such as when there is nerve compression. But for an overwhelming number of patients with low-back pain, non-surgical treatments prove just as effective.
How can we explain the higher incidence of patients undergoing a complex and often ineffective procedure? Welcome, once again, to America’s perverse fee-for-service payment model.
In America, health care providers are rewarded for the quantity of patient visits, tests and procedures. Achieving the exact same result without surgery pays dramatically less than performing a risky intervention.
Surgeons and hospitals make much more money from surgical intervention than from conservative treatment. Clearly, they act accordingly.
Why do we think more care is better for us?
In a word: culture. That applies to both American culture and the culture of medicine.
We want to believe that doctors have all of the answers. We want to believe physicians can cure almost anything. And we want to believe that a routine check-up, prostate exam or back surgery adds value.
We love anecdotes about a surprise diagnosis leading to a life-saving treatment — or about a patient who was miraculously cured by a procedure. But we often leave out stories about patients who experienced only temporary relief or, worse, suffered serious complications.
Of course, doctors should never withhold necessary and effective care. There are many problems for which invasive procedures lead to the best outcomes and we need to encourage their use. But we should examine the scientific evidence first and not make decisions based on fairytale anecdotes or the potential for higher reimbursements.
In the United States, there are so many health problems that suffer from lack of attention. High blood pressure, for instance, is a leading cause of death and disability in the U.S., but physicians only achieve control of their patient’s elevated blood pressure levels half of the time.
If we want to improve the health of our nation, we need to reduce the cost of medical treatment and stop wasting money on care that adds no value.
Until we reward doctors and hospitals for the quality of care — rather than the quantity of care — we’ll continue to lead the world in spending. But, at the same time, we’ll never lead in superior clinical outcomes. And until we bust the myth that more is better, little is likely to change.