Jun 7, 2010

The Overtreatment-Undertreatment Debate Rises Again

Today’s Boston Globe (HERE) tackles a health issue that scarcely deserves another run through the news mill, but apparently carries some reader appeal so they’ve tackled it (again).  Yes, it’s the ills of overtreatment.  We’ve all heard the statistics; Americans receive too much treatment, too often, at too much cost, with too little benefit.  This article does little to add to our understanding of the issues.  However, it’s worth noting since articles of this nature, of which many more will come, will lay the groundwork for policymakers, and provide previews of the future, as we move deeper into health reform.

The piece starts off with the usual shock ‘em line, “Too much medical treatment is making many Americans sicker”, then quickly veers away from health concerns and, not surprisingly, quickly ends up at cost.  The usual suspects are targeted, among them including excessive C-sections, end-of-life care, CT scans, stents, and even antibiotics.  Amazingly, the authors make few attempts to draw any connection between the use of these procedures and treatments and worsening health. Rather they quickly move to how physicians are going to be saved from continuing their deviant ways: ”Efforts are under way to help doctors ratchet back avoidable care and help patients take an unbiased look at the pros and cons of different options before choosing one.”  Which brings us to Preview of the Future #1: More people than populate our purported brainy state (Massachusetts, of course), will be self-appointing, elected, or appointed by elected officials to help physicians be better physicians.  That’s comforting.

This statement is followed by a quick hand-wave at healthcare rationing, just in case you were getting concerned. "This is not, I repeat not, rationing," said Dr. Steven Weinberger of the American College of Physicians. This affords us Preview of the Future #2: Rationing will occur, but few if any will admit it, and the more vehemently in denial, the more likely they are aiding and abetting.

Next the piece sets out to help us understand the difference between under- and over-treatment, with slight poetic license. “Under-treatment was in the headlines over the past year as the Obama administration and Congress wrestled with legislation to get better care to millions who lack it”, we are told.  Funny, that description sounds like under-insurance, which often leads to under-treatment, but is not exactly the same.  In fact, many who have proper insurance are under-treated regularly.  Pick your favorite chronic disease, any one of them, and you’ll find the ranks filled with those that are insured but under-treated.  Maybe it’s just semantics, but redefining basic concepts and use of moving targets are the hallmarks of slow but important cultural shifts.

Finally, they get to the point of the article, the real point, in plain language.  “The flip side, overtreatment, is a big contributor to runaway health care costs.”  

Lastly, we get to Preview of the Future #3: Physicians will be portrayed as unable to control themselves, therefore, more sophisticated systems will be needed to help them along.  This is the same argument that has given rise to the new regulations that prevent a physician from having a coffee with someone from the pharmaceutical or device industries (see Dana & Loewenstein, JAMA 2003 HERE for the origins of this conflict of interest argument).  Here’s how the Globe articulates the issue: "Physicians get up every day with the good intentions of wanting to do what's best for their patients," said Dr. David Goodman of the Dartmouth Institute for Health Policy. "We also live in environments where there are strong financial incentives to deliver certain types of care. We get well-paid for doing procedures. We get paid relatively poorly for spending time with patients and helping them make choices."  In other words, physicians want to do the best for patients, BUT … they just can’t.  Luckily, there will be legions of public servants, elected or appointed, to help guide them toward better patient care.

There’s more in the article, but mostly just anecdotes supporting these arguments.  What’s more interesting is the fact that not a single comment has been posted to what should be a fairly provocative article.  Certainly a sign that we are already numbed to what is actually being said in articles of this ilk.  Nonetheless, it’s worth keeping an eye open for these articles and doing a little additional analysis.  You’re guaranteed to find a lot more in days to come.