Here Comes Medical Rationing
Bea Attitude
http://news.yahoo.com/s/ap/20100607/ap_on_he_me/us_med_overtreated
… By LAURAN NEERGAARD, AP Medical Writer Lauran Neergaard, Ap Medical
Writer – Mon Jun 7, 9:43 am ET
WASHINGTON – More medical care won't necessarily make you healthier —
it may make you sicker. It's an idea that technology-loving Americans
find hard to believe.
Anywhere from one-fifth to nearly one-third of the tests and
treatments we get are estimated to be unnecessary, and avoidable care
is costly in more ways than the bill: It may lead to dangerous side
effects.
It can start during birth, as some of the nation's increasing C-
sections are triggered by controversial fetal monitors that signal a
baby is in trouble when really everything's fine.
It extends to often futile intensive care at the end of the life.
In between:
_Americans get the most medical radiation in the world, much of it
from repeated CT scans. Too many scans increase the risk of cancer.
_Thousands who get stents for blocked heart arteries should have tried
medication first.
_Doctors prescribe antibiotics tens of millions of times for viruses
such as colds that the drugs can't help.
_As major health groups warn of the limitations of prostate cancer
screening, even in middle age, one-third of men over 75 get routine
PSA tests despite guidelines that say most are too old to benefit.
Millions of women at low risk of cervical cancer get more frequent Pap
smears than recommended; millions more have been screened even after
losing the cervix to a hysterectomy.
_Back pain stands out as the No. 1 overtreated condition, from
repeated MRI scans that can't pinpoint the trouble to spine surgery on
people who could have gotten better without it. About one in five who
gets that first back operation will wind up having another in the next
decade.
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!"
The Associated Press combed hundreds of pages of studies and quizzed
dozens of specialists to examine the nation's most overused practices.
Medical groups are starting to get the message. 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.
"This is not, I repeat not, rationing," said Dr. Steven Weinberger of
the American College of Physicians, which this summer begins
publishing recommendations on overused tests, starting with low back
pain.
It's trying to strike a balance, to provide appropriate care rather
than the most care. Rare are patients who recognize they've crossed
that line.
"Yet let me tell you, with additional tests and procedures comes
significant harm," said Dr. Bernard Rosof, who heads projects by the
nonprofit National Quality Forum and an American Medical Association
panel to identify and decrease overuse.
"It's patient education that's going to be extremely important if
we're going to make this happen, so people begin to understand less is
often better," he said.
Not even doctors' families are immune.
A hospital appropriately did six CT scans to check Dr. Steven
Birnbaum's 22-year-old daughter for injury after she was hit by a car.
But the next day, Molly had an abdominal scan repeated as a precaution
despite having no symptoms. When a doctor ordered still another, "I
blew a gasket," said the New Hampshire radiologist, who put a stop to
more.
___
There are numerous reasons that one of three U.S. births now is by
cesarean, but Dr. Alex Friedman blames some on an imprecise monitor
strapped to laboring women. Too often, he has sliced open a mother's
abdomen fearing the worst, only to pull out a pink, screaming bundle.
"Everyone knows it's a bad test," said Friedman of the Hospital of the
University of Pennsylvania. "You haven't done the patient a big
service by doing an unnecessary surgery."
Electronic fetal monitors record changes in the baby's heart rate, a
possible sign of too little oxygen. They became a tradition — now used
in 85 percent of births — years before research could prove how well
they work.
Guidelines issued last summer, aiming to help doctors better interpret
which tests are worrisome, acknowledge the monitors haven't reduced
deaths or cerebral palsy. But they do increase the chances of a C-
section. While they should be used in high-risk women, the guidelines
say the low-risk could fare as well if a nurse regularly checked the
baby's heart rate.
Later this year, the National Institutes of Health will begin a major
study to see if adding a newer technology — a type of fetal EKG
already used in Europe — to the heart-rate monitor would better
identify which babies really are struggling and need rapid delivery.
___
Undertreatment 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.
The flip side, overtreatment, is a big contributor to runaway health
care costs. Yet it's one that lawmakers, wary of being accused of
rationing, largely avoided in the new health care law. Included were
modest steps — studies to compare which treatments work best, some
Medicare financial incentives — to push higher-quality, lower-cost
care.
"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."
Where you live plays a role. Two decades of research from the
respected Dartmouth Atlas of Health Care shows that in parts of the
country, Medicare pays double or triple the price to treat people with
the same illnesses. The differences are not fully explained by big
cities' higher cost of living or populations that are poorer, older or
sicker. How much care someone gets is a main reason, yet Dartmouth's
data shows people in pricier areas don't necessarily fare better.
Dartmouth's check of 2005 Medicare data found that during their last
six months of life, older adults in Boise, Idaho, spent 5.3 days in
the hospital compared with 17 days in Miami.
Fee-for-service care and local habits aren't the only drivers.
Fear of malpractice lawsuits "has everything to do with it," said Dr.
Angela Gardner, president of the American College of Emergency
Physicians, whose members face intense pressure to overtest in the
life-and-death chaos of the ER.
Nor is there always clear evidence for one therapy choice over
another. It can be faster to give in to a patient's demand for
medicine than to explain why, for example, a child doesn't need
antibiotics for ear pain.
___
Care for the dying is often a powerful illustration of treatment going
too far.
Texas author Liza Ely had lined up hospice care for her 93-year-old
mother, Verna Burnett, as she lived her last days with Alzheimer's and
heart failure. Yet when Burnett developed an irregular heartbeat, the
care provider at her Tyler, Texas, nursing home recommended seeing a
cardiologist, to have a tube threaded through blood vessels to her
heart to check it out.
"We were speechless," Ely said. "We asked what could be done if
something showed up on the test."
The response: "Nothing, really."
Ely said the family refused the "painful, expensive and unnecessary
test."
Congress' health care overhaul initially included a provision that
would have authorized Medicare to pay doctors for counseling patients
interested in end-of-life options. The provision died in the hue and
cry after Sarah Palin dubbed the effort "death panels," a charge named
2009 political "Lie of the Year" by the nonpartisan fact-checking
organization PolitiFact.
Rep. Earl Blumenauer, D-Ore., said he plans to reintroduce his idea.
"Today there is no guarantee that people will get the care they want
when they are incapacitated or in those final stages of life. The
default is sometimes the most painful, the most intrusive, the most
frightening treatment — whether or not that is what people want," he
told the AP.
___
New efforts are beginning to push back against overtreatment:
_In Minnesota, the influential health cooperative HealthPartners saw
use of MRIs and radiation-heavy CTs growing between 15 percent and 18
percent a year. So the insurer began a new program: National radiology
guidelines pop up on each patient's electronic medical record whenever
a doctor orders a scan. It's not a requirement, but a gentle reminder
of when such tests are recommended.
In two years and counting, HealthPartners estimates it avoided 20,000
unnecessary tests, preventing dangerous radiation exposure and saving
$14 million.
Providing the guidelines helps doctors deal with patients who demand a
scan, says medical director Dr. Pat Courneya. He recently examined a
young man who wanted a brain CT because of dizziness. Courneya's
physical exam turned up no neurologic red flags like weakness or eye
problems, but seeing the guidelines helped reassure the man.
_An American Medical Association journal, Archives of Internal
Medicine, just began a "Less is More" series to educate doctors about
the risks of overused treatments.
First up: Studies saying more than half of the 100 million-plus
prescriptions for the strongest stomach acid suppressors — proton pump
inhibitors such as Nexium — go to people who don't need something that
powerful. That puts them at unnecessary risk of side effects,
including bone fractures and infections.
_This summer, the journal Annals of Internal Medicine begins
publishing American College of Physicians' guidelines for "high-value,
cost-conscious care."
_To increase patients' savvy, about a dozen health centers around the
country are testing "shared decision-making." That process uses plain-
English guides, often DVDs, to explain the advantages and
disadvantages of test and treatment options. Given full information,
patients choose a less aggressive approach than doctors initially
recommend about 20 percent of the time, says Dr. Michael Barry of the
nonprofit Foundation for Informed Medical Decision-Making.
"Where I think no one in the Consumer Reports age would go to the car
lot and say, 'I'm going to let the dealer figure out what car I want
or need,' now we are taking a little of that spirit to the doctor's
office," he said.
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