by John Weeks
This presidential campaign season has made common knowledge that, when it comes to spending on healthcare, the United States is in a class of its own. Total spending hit $2.1 trillion in 2006. In 2007, we were spending $6,400 per capita, nearly 50% more than in Norway, the next highest spender. Candidates on both sides of the aisle offer plans to reform the system.
Large employers are not waiting around for political action. Companies have a bottom line interest in the health of their employees. Business competitiveness is at stake. I recently attended a conference of employers in Seattle hosted by the Boeing Company and led by the Institute for Health and Productivity Management (IHPM- www.ihpm.org ). Diverse strategies are being explored: pedometers, motivation, empowerment, information, incentivizing, modeling, and more. I attended the meeting to better understand the role complementary, alternative and integrative medicine (CAIM) services CAIM might have in these efforts.
Yet in the back of my mind during the entire meeting was an assertion which made pale the cost savings strategies of both the candidates and of these large employers. My colleague and fellow health writer, Elaine Zablocki, had sent me a book. Elaine’s ostensible reason was that she wanted to quote my opinion of the book in her own review. She also had another agenda. Elaine was sold on the book’s power and guessed that I, too, would start sharing it with others. She guessed right.
What I had read in the book haunted me as I reflected on the public and private strategies to reform medicine. Consider this, from the book’s introduction:
“ … We spend between one fifth and one third of our health care dollars … between five hundred billion and seven hundred billion dollars (and that’s a billion, with a b), on care that does nothing to improve our health. And while overhead and high prices hurt our pocketbooks, the vast amount of unnecessary care in the system also makes our health care worse than it ought to be.”
The book is Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer. The book was not written by some alternative medicine or integrative care advocate. The author, Shannon Brownlee, practiced her craft in such mainstream publications as US News & World Reports, New York Times Magazine and the Atlantic Monthly. Brownlee’s core informants are sources like Jack Wennberg, MD, who headed a two-decade examination of cost-related issues at Dartmouth (www. http://www.dartmouthatlas.org/) and Donald Berwick, MD, the reforming taking on hospital-caused deaths at the Institute for Health Improvement at Harvard (http://www.ihi.org/ihi), and the US Institute of Medicine which published the landmark To Err is Human in 2000 (http://www.iom.edu/?id=12735).
Brownlee summarizes these evidence-based analyses. The resulting story is well-known inside the employer, health care analyst and policy maker world. Somewhere between $500,000,000,000 and $700,000,000,000 spent unnecessarily each year is not only hurting us economically. The excessive treatment is also likely, as Brownlee states, to be causing harm. Estimates place medical treatment at between the 3rd and 5th leading cause of death in the United States with an estimate published in the Journal of the American Medicine Association placing the number at 225,000 from iatrogenic causes (1-4) Stated bluntly: We are not only given far more treatment than is necessary. We are likely to be harmed by the additional care.
Of course, none of these estimates take into account what might be gained from a system that featured integrative approaches organized around using the least invasive therapies. What cost savings and health creating outcomes might that achieve?
My informal sharing of this information to friends and colleagues quickly taught me that even well-informed people have little sense of the dimensions of our problems. Try asking your friends the following questions and see how close they are to describing medicine’s role in our lives:
- How much did the US spend on medical care in 2006?
- What percent is unnecessary overtreatment?
- Has this high level of treatment created better outcomes?
- Is medical treatment a leading causes of death? If so, what place does it hold?
As I listened to the conference presentations on informing, empowering and incentivizing employees, I was struck that we could benefit immensely from a different kind of information and empowerment strategy than was being recommended. Why do we not have a public health campaign warning every man, woman and child that the medical care they receive may be unnecessary, expensive and hazardous to their health? Imagine bus signs, billboards, full page magazine ads and public service announcements:
Sick? You might get sicker.
Beware of overtreatment in your hospital.
Consumers could be sent to a public health website that guides them through the best literature on their options. Training modules could teach consumers how to talk with their physicians about avoiding overtreatment. Top 10 or Top 50 lists could guide people to surgeries and tests most likely to be unnecessarily performed.
In the discussion period at the end of the employer seminar, I asked the group why we were not aggressively equipping all healthcare consumers with this information. Why don’t we require hospital advertisements to share the likelihood of adverse events such as those required in the advertising of pharmaceuticals? Warning – Some of the procedures and surgeries performed in this hospital may be unnecessary and harmful. It is complex, I was told. It is not as simple as that.
Yes, none of this is simple. Our politicians have a poor track record – dating back 45 years - on medical reform. Though the capitalist incentives in our current system drives overtreatment, as Brownlee’s stories and analysis quietly and repeatedly point out, elected officials show little sign of creating changes which will dampen this behavior. Meantime, the American Hospital Association publicizes its importance to local economies in jobs creation.(5) Think for a minute of what appropriate, evidence-based care, as described by Brownlee, would do to the AHA’s brag sheet of direct economic impacts? None of this is simple.
The situation Brownlee describes in Overtreated is hard to accept. Then again, I don’t imagine it was easy for smokers or tobacco companies to accept seeing data on smoking turned into a public health campaign. We have the data. What we need is an extraordinary, straight-talking, consumer-oriented effort which empowers patients to ask critically important, life-and-death questions of their hospitals and practitioners about the care that is, or may be, recommended. If consumers are not aware of these data, they are less likely to take active roles in their processes.
My guess is that less-invasive, outpatient, integrative practices might be big winners from such a campaign. Who knows, with adequate education about risks of the care they receive as passive and uninformed recipients, people might start thinking about taking better care of their selves.
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