President Obama has stressed the importance of “bending the cost curve” in order to put the brakes on galloping health care expenses that total 2.5 trillion dollars a year and are increasing at 6% a year. The fastest way to do this is shockingly simple: carefully explain to patients the known risks and benefits of procedures.
Dr. Elliott S. Fisher, Director of Dartmouth’s Center for Health Policy Research, estimates that thirty to forty percent of elective procedures are unnecessary. This includes elective angioplasty ($16,000), spinal fusion ($22,300), knee replacement ($14,400), and hip replacement ($15,700).
And it’s not just costly procedures that are ballooning our health tab; the annual price for diagnostic imaging studies such at CT’s and MRI’s is about 100 billion dollars, roughly 35% of which is estimated to be wasted.
A prime example of an overused procedure is angioplasty, which opens up clogged arteries in the heart. Over a million are performed every year in the United States. Most patients believe it will prevent a heart attack and prolong life. But that’s only true if the procedure is performed when a patient is actually showing signs of a heart attack. In elective cases which, according to the American College of Cardiology’s National Cardiovascular Data Registry, account for 37% of angioplasties, it has not been shown either to prevent heart attack or prolong life. For a segment that aired last June on the CBS Evening News with Katie Couric, cardiologist Dr. Steven Nissen of the Cleveland Clinic told me, “Cardiovascular interventional procedures are big money makers for hospitals and for practitioners.” For a lot of doctors, “it’s tough to walk away from that.”
Our fee-for-service payment system certainly creates perverse incentives for doctors, a major reason for the spiraling cost of health care. But there is another factor that is more insidious: the reluctance of physicians to accept new evidence about the medicine they practice. For example, doctors have been taught for many years that an open artery is always better than a closed one. Despite convincing data showing that this simply isn’t true, many physicians remain unconvinced and refuse to change their behavior.
When I interviewed President Obama about health care in July, I asked him about unnecessary elective angioplasties and the friction between what a physician believes to be true and what is supported by evidence-based medicine. He replied, “I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we’re honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we’re reimbursing the physician not on the basis of how many procedures you’re performing but rather how are you caring for the patient overall – what are the outcomes – then I think you start seeing some different choices.”
Trying to figure out which medical interventions actually work is the whole point of the so-called “comparative effectiveness” studies for which Congress has budgeted 1.1 billion dollars. There has already been good progress in this kind of research. Aside from data showing that elective angioplasties don’t save lives, a recent study found that vertebroplasty, a common procedure to treat pain from back fractures, was no better than a placebo treatment with a shot to temporarily numb the area.
Ultimately, insurers will try to change behavior by refusing to cover services that have performed poorly in comparative effectiveness research. That strategy will likely take years to implement and will be complicated by the fact that medicine is both an art and a science and will never be able to be reduced to perfectly predictable algorithms. Clinical judgment and even what has recently become a politically incorrect term – intuition – will always play an important role.
So how do we save billions starting now? By doctors and patients agreeing to discuss carefully whether procedures and tests are worth it.
This will have to involve consent forms. A review of hundreds of these forms at more than 150 hospitals found them to be of “limited value.” They are loaded with confusing language, often omit specific risks and benefits, and are generally not well explained by doctors. Patients often sign the forms minutes before a procedure without even reading them. Experts such as Dr. Fisher say that 30-40% of unnecessary procedures could be eliminated through proper informed consent – what is increasing being called “informed patient choice” to emphasize that doing the suggested procedure is not a foregone conclusion.
Gerry O’Connor, PhD, Associate Dean for Health Policy and Clinical Practice at the Dartmouth Hitchcock Medical Center, has implemented a pilot program that personalizes the consent process. In the case of angioplasty, the physician collects detailed medical information about a patient, then searches a database of angiogram results to estimate individual risks and benefits by finding out what happened to similar patients who had the same procedure. “It’s not generic,” he told me. “It’s for people like you. If we get that right, we’ll create a better informed consent.”
Ultimately, electronic medical records will connect with electronic medical knowledge, including comparative effectiveness results, to give doctors and patients information – so-called “decision support” – at the moment a test or procedure is electronically ordered. But until then, and starting immediately, doctors and patients can try the low-tech solution of setting aside enough time to weigh adequately the pros and cons of medical options – not just for procedures but for other treatments and diagnostic studies. Of course, this is more easily said than done in a system that reimburses far better for doing things to patients than for communicating with them. That must change.