Monday, June 7, 2010

Overtreatment in the news

Overtreatment means someone could have fared as well or better with a lesser test or therapy, or maybe even none at all. Avoiding it is less about knowing when to say no, than knowing when to say, "Wait, doc, I need more information!"

It's great this is in the news but again the way overtreatment is framed leaves people without a clear picture of the harms.  They do mention a risk of cancer with excessive CT scans but they refer only to the "limitations" of PSA screening.   They don't mention the harms of screening mammograms at all.  They don't mention the blockbuster (expensive) vaccines gardasil and prevnar which have more evidence of harm than benefit.  

They mention a couple medications which are overprescribed such as Nexium and antibiotics but they again leave the magnitude of harm vague.  

It's interesting to watch the system attempt to retreat slightly and reduce the overtreatment burden slightly with guidelines and payment incentives for physicians to counsel more and test/over treat less.  

Amend and reform,  amend and reform.   

But what if the core of the system is rotten?  

What if the fundamentals of health care incentivize overtreatment?  How are some guidelines going to counteract the massive marketing power of pharmaceutical companies?  

See it's times like these that "lip stick on a pig" would be appropriate but our friend Sarah P ruined that gem for us all.   

Oh well.  

But this article does sample a pretty large chunk of the super-sized american health care experience.  It's a superficial view of the harms from all this over testing, over treating.   It doesn't make the connection between overtreatment and marketing.  It doesn't make the connection between over everything and lack of coverage via high costs.  

It doesn't talk about how overtreatment and over testing are the same things as economic growth in the so called health care industry.  


IF we somehow reverse this trend toward more and more unnecessary/harmful health care,  then what will it do to the economy?  I mean other than the military and other government spending, health care has been one of the few consistent sources of economic growth.   Do we really have a system that punishes society with yet another bursting bubble (dot com followed by housing followed now by health care) because society finally figures out that more is less?

Because as we break this mindless cycle of excessive treatment and testing and reduce the harms that go with it all,  some mighty powerful industries will be forced to shrink and good, hardworking people will be out of a job.   

The stuff about low back pain in the article reminds me of a local phenomenon.   Here in Yakima one of the few highly lucrative health care institutions is the pain clinic.   The pain clinic functions as a kind of deep injection factory.  Nerve blocks,  epidurals,  spinals.  These deep injections often under xray guidance pay very well.  The benefits are almost always short-lived and the potential harms remain vague in most minds but the financial incentives to do more tests and more procedures are painfully evident at the pain clinic.  

And now that the ER has a fancy new MRI scanner,  there's even more opportunity to find common disc abnormalities that can be harvested at the pain clinic.  

But almost all of their business at the pain clinic is discretionary spending.  Most of the patients walking in their doors will either get better on their own and/or not benefit from the procedures preformed.  

It's not that we don't need specialists who can do nerve blocks well.   It's just that the incentive to do more procedures,  advertise and repeat runs counter to the best interests of the average patient in pain.  

Put another way:   If most people with low back pain will get better just as rapidly with certain treatments as without,  then most people are harmed in some fashion by said treatments. 

It's pretty grotesque but almost every popular AKA lucrative treatment and test in medicine is over applied.  It just makes sense,  if you limit interventions to just the people who need them, you are missing out on a larger market.   The goal, financially, of any medical intervention is to apply something studied in a limited population of patients to the general population.  

Like with acid blockers like Nexium.   If it works well in people with ulcers then focus on the symptoms that are most common in the general population and get people used to treating the symptoms.   There are thousands of times more potential customers who have occasional heartburn versus the rare individual with stomach ulcers.  

Interesting times