“Overkill: An Epidemic of Unnecessary Medical Care” was the title of a recent article by Atul Gawande, the Harvard-based physician who frequently writes for the New Yorker. In his article, he quotes a 2012 Institute of Medicine report stating that waste accounted for 30% of health-care spending ($750 billion per year), “which was more than our nation’s entire budget for K-12 education”.
More importantly, the Institute of Medicine reported in 1999 that up to 98,000 people a year die because of mistakes in hospitals. In 2010, the Office of Inspector General for the Department of Health and Human Services said that bad hospital care contributed to the deaths of 180,000 Medicare patients in a given year. And then in September 2013, the Journal of Patient Safety that says the numbers may be much higher — up to 440,000 patients/year suffer preventable harm resulting in death.
Does this matter to me?
Every day we are inundated with nausea-inducing statistics from far away. But the research shows that nearly everyone of us has been directly affected. Many of us are taking meds we don’t need, have had unnecessary surgery, labs and tests. Far worse than the sometimes devastating financial impact of these mistakes, some have actually died from these unnecessary measures.
Dr. Gawande, who is a surgeon, speculates, “We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”
As a Primary Care doctor in Annapolis for nearly 20 years, I have personally seen many examples of unnecessary care and disastrous outcomes. In my experience, in addition to Dr. Gawande’s reasons above, the level of training and experience also play a very important role. Lesser trained or experienced providers tend to order more tests–going on what we term “a fishing expedition.” It’s important to note that some of the BEST providers I’ve ever worked with are NPs and PAs. I’d rather refer my mom to an experienced NP or PA than a rushed, inexperienced, uncaring or poorly trained MD.
In my career, I’ve seen a lot of CT scans, MRIs and blood tests that seemed to be completely unwarranted but were ordered because the provider didn’t know where to look and instead threw out a huge net. In fact, every year in the US, people get over 100 million CT and MRI scans, and 10 billion laboratory tests.
Historically, in urgent care and the ER, the rule has been “When in doubt, rule it out (with a test).” This may simply be because there is no continuity of care. Sometimes the best solution is “Let’s see you (or talk) again in a day or two.” The ability to follow up is critical and lacking in most EDs and urgent care systems where you rarely see the same person twice. In fact, continuity of care and follow up is a primary focus of my clinic, Evolve Medical.
Another culprit for excessive testing is the current legal malpractice system. Most of us are familiar with the excessive testing providers do to cover themselves (see cartoon to the left). What we are starting to now realize is just what the cost of those unneeded tests may be–to society and to the individual.
Whether you are seen at an urgent care or ER setting, chances are you will never see that provider again–or be able to contact the exact provider again. On the other hand, if your primary care provider knows you and has a relationship, then they are more apt to consider a longer term approach than the quick, often unnecessary test or procedure.
How does excessive testing hurt people?
CT scans represent a good example of how excessive testing can be harmful. According to the FDA, a CT scan of the abdomen delivers the equivalent of 400 chest X-rays of radiation and is equal to 2.7 years of natural background radiation exposure.
They can also hurt in another way–financially. In the days of HMOs, when insurance paid for everything, CT scans, lab tests and procedures were financially painless. Now, with higher deductibles, many of us are paying for these unnecessary and potentially harmful procedures.
Finally, they can hurt in a 3rd way: by finding an unexpected abnormality that after follow up CT scans, MRIs, ultrasounds and surgery eventually turns out to be “nothing to worry about.” Meanwhile, the patient has spent months worrying and thousands of dollars. And sadly, some of these folks end up dying from one of the hospital-related complications discussed above.
Is there a solution?
The Institute of Medicine recommends that health care should be better-coordinated, doctors should follow up with patients and there should be continuity of care.
The bottom line is that a system of rushed providers who don’t have time to think or explain things to their patients is not working. It is for this reason that Annapolis’ Evolve Medical Clinics and other Direct Primary Care offices are being touted by everyone from Michael Dell, Jeff Bezos, and Google to bi-partison Senators and Congressmen as a major step toward the solution.
Changing the reimbursement plan from fee-for-service to membership based primary care removes the time constraints and perverse financial incentives. Direct Primary Care doctors not only have the time to make the right diagnosis–by listening–but can also focus on advocating for their patients, saving them from unnecessary surgeries, tests and medications. In 2012, the British Medical Journal showed astounding results with Direct Primary Care:
- 35% fewer hospitalizations
- 65% fewer ER visits
- 66% fewer specialist visits
- 82% fewer surgeries
We are living in a medical world wherein there is an epidemic of unnecessary care and a lot of that care has caused doctors and hospitals to be a major killer, possibly worse than cancer or heart disease, if we believe the 440,000/deaths per year estimate.
We recommend that whenever possible, people establish care with a Primary Care provider. And use that person as the central “contractor” for your health.
Your Primary Care provider should advocate for you: does this test need to be done? Do I need this surgery? Can I save money on this medication–or do I even really need it? He or she should be accessible, easily, via phone or email. And you must be able to see them when you need them–and to follow up with them. If you have a Primary Care that can offer you continuity of care, is willing to coordinate your care and has the ability to spend the time with you that is necessary, it will go a long way towards protecting you and your family from what has become a dangerous system.