Overutilization

"The United States spends substantially more per person on health care than any other country, and yet U.S. health outcomes are the same as or worse than those in other countries." So begins a commentary by Ezekiel J. Emanuel, a bioethicist at the National Institutes of Health, and Victor R. Fuchs, the well-regarded health care economist at Stanford University, which appears today in the Journal of the American Medical Association.

Welcome to the fray, gentlemen.

I don't need to go over the various statistics and health outcome anomalies covered in their essay, most of which have appeared at one time or another on this blog, in recent books like Shannon Brownlee's "Overtreated" and Nortin M. Hadler's "Worried Sick," or in the most recent reports of the Congressional Budget Office, which I reported on here and here. Bottom line: about 30 percent of health care expenditures are a waste, medically unnecessary, and, for all intents and purposes, a make-work program for physicians, drug companies, device companies, hospitals and everyone else on the health care 16-percent-of-GDP-and-rising gravy train.

So let's cut to the chase and go to their discussion about solutions. "Changing Americans' affinity for new technology is somewhere between difficult, impossible, and undesirable," they write shortly after agreeing that much of what is new isn't really better than the old.

How about changing physician training and practice so they are less dependent on commercial forces, less likely to generate high-priced specialists, and short-change primary care? Calls for changing physician education are "usually ignored," the soberly write. "Rapid reforms of medical education and training, even when widely acknowledged as essential, are uncommon."

Okay. How about curbing aggressive marketing to physicians by drug companies and other providers? "Such changes alone are unlikely to have a large effect on overutilization." Malpractice reform? "Reform would affect only some defensive practices."

So what is the most effective reform in their eyes? "More value-based co-payments, modeled on current tiered pharmaceutical benefits, that link the amount patients pay to effectiveness and cost of alternatives. . . this is not an all-or-nothing rationing scheme, but rather an ethical way to have patients experience costs but not at the expense of important outcomes."

Ah, I see. The market will save us through higher co-pays. I am dubious. When I go to the doctor, I rely on my learned intermediary to tell me what is necessary. Must I, Patient, now become I, Health Care Consumer, when I am sick and vulnerable? Must I conduct an internet search of the latest articles on PubMed and the U.S. Preventive Services Task Force database before determining if I should shell out an extra $30 for that test or drug? Or, should I simply reject these offered treatments because my insurance company decided they deserved a higher co-pay?

But more significantly, why am I, Patient, being asked to make these decisions at all? How many years of medical school do I have under my belt? Isn't that my doctor's job? Why don't they recommend the creation of a reimbursement scheme for the learned intermediaries who order up every diagnostic test, drug, and procedure which will encourage the doctors to use the most effective and cost-effective care? If we can have a three-tier co-pay scheme for patients, why not a three-tier reimbursement for doctors and hospitals? Market signals would work just as well for producers as for consumers, would they not?

Can't go there yet, say Emanuel and Fuchs. "Many more experiments are needed" before payers can implement pay-for-performance, bundled payments, partial capitation, value-based payment or "other payment methods to promote prudent use of resources."

Curiously, Emanuel and Fuchs make no mention of creating a comparative effectiveness agency to let patients and physicians alike know what works best. They simply presume that somebody -- the insurance companies that they admit waste $50 billion a year in excessive administrative costs, or the Center for Medicare and Medicaid Services, which is routinely defanged by Congress or special interests, who successfully lobby to get their new technologies paid for -- will be able to set appropriately tiered co-payments that will send consumers the market signals and hold down costs.

It is now a generally accepted fact that 30 percent of all health care expenditures are wasted. This statistic is hammered home year after year by the Dartmouth Atlas of Health, which compares outcomes in low-spending areas of the country to outcomes in high-spending areas and finds they are usually about the same. The implication of their work is that it is going to take a radical overhaul of the way medicine is practiced -- by physicians, by hospitals, by suppliers -- if the nation is ever going to put a brake on its ever-rising health care costs.

Emanuel and Fuchs understand the problem. Indeed, their essay this morning reflects what is rapidly becoming the conventional wisdom, which is summed up in their headline: "The Perfect Storm of Overutilization." Alas, like all too many diagnosticians of the rising health care costs crisis, they shy away from the radical prescriptions it will take to cure the disease.

Posted by gooznews at June 18, 2008 06:45 AM