Stemming the tide of overtreatment in U.S. healthcare
CHICAGO (Reuters) - A leading group of U.S. doctors is trying to tackle the costly problem of excessive medical testing, hoping to avoid more government intervention in how they practice.
The American College of Physicians (ACP), the largest U.S. medical specialty group, is rolling out guidelines to help doctors better identify when patients should screen for specific diseases and when they can be spared the cost, and potentially invasive procedures that follow.
Many individual U.S. medical centers have launched their own efforts to build a protocol of patient care in fields such as diabetes or obstetrics, but the ACP effort has the potential to influence doctors nationally. ACP members include more than 132,000 physicians, mainly focused on internal medicine.
"Excessive testing costs $200 billion to $250 billion (per year)," Dr. Steven Weinberger, CEO of ACP said in an interview from his office in Philadelphia. "There's an overuse of imaging studies, CT scans for lung disease, overuse of routine electrocardiograms and other cardiac tests such as stress testing."
In an article published last month in the Annals of Internal Medicine, the ACP cited 37 clinical situations where screening did not promote health and might actually hurt patients.
They included performing coronary angiography - a procedure that uses a special contrast agent and X-rays to see inside the heart's arteries - in patients with chronic, stable chest pain that is being controlled by drugs or who lack specific high-risk criteria on exercise testing.
"It's medical gluttony," said Dr. Otis Brawley, chief medical officer of the American Cancer Society.
"The ironic thing is that people are talking about rationing. We have got to think about the rational use of medicine in order to avoid rationing medicine," he said.
For Weinberger, establishing guidelines on when to perform a range of diagnostic tests in order to cut waste out of the healthcare system is one of his top priorities at ACP.
He should enjoy broad-based support, as U.S. healthcare costs reached $2.6 trillion in 2010, contributing to a spiraling national deficit. That's $8,086 per person, or 17.6 percent of the nation's gross domestic product, government figures show.
Yet there certainly will be protests from some doctors who decry guidelines as undermining their judgment and the art of practicing medicine. Guidelines may also cut into their income.
President Barack Obama's health law from 2010 recognizes the growing burden of costs, but its main goal was to extend healthcare coverage to millions more Americans. It deals indirectly with ways to curb expenses.
The Obama administration's proposed budget for the coming year seeks to wrest more than $360 billion in health savings in the next decade by curbing payments to doctors, among other measures.
Health economists and other policy advisers question whether doctors can be trusted to make the right calls.
A study published in the October 2011 issue of the British Medical Journal showed that almost half of doctors involved in setting clinical guidelines in the United States and Canada for diabetes and cholesterol between 2000 and 2010 had conflicts of interest. See: here
"I don't trust professional societies to do it because that's how they make money - by doing tests and procedures," said MIT healthcare economist Dr. Jonathan Gruber.
He cites estimates that about $800 billion - or nearly one-third of all healthcare spending - is wasted in unnecessary diagnostic tests, procedures and extra days in the hospital. Treatment guidelines will help curb overuse, but Gruber and others would prefer the government set them.
The ACP last year published guidelines on using imaging studies to evaluate lower back pain, a common ailment where expensive diagnostic evaluation does not always help and sometimes hurts patients.
Medicare data show that doctors often order MRI scans for patients with lower back pain who have not tried less invasive, less expensive treatments such as physical therapy. An MRI frequently leads to surgery, data show.
One study by the National Institutes of Health that used data from the government's Medicare health plan for the elderly concluded doctors who prescribe MRI scans, which can cost $3,000, tend to follow up with even more expensive surgery. See: here
Dr. Daniel Resnick, a neurosurgeon who specializes in spine surgery, has been involved for years in establishing guidelines with the North American Spine Society, which represents 6,500 physicians. He said some fellow surgeons "got very angry" when his group rolled out guidelines.
For years, spine surgeons treated certain types of back pain by fusing the front and the back of two disks, which for billing purposes were two separate procedures, he said. Today, guidelines recommend fusing either the front or the back of the disks, not both.
"It's like wearing a belt and suspenders. There was a 'more is better' type of thinking. But we found evidence that doing more was worse than doing less," he said. "There was pushback. Some felt guidelines interfered with their decision-making. That they were promoting cookbook medicine."
Resnick said he respects the ACP effort and believes it is the responsibility of medical societies to develop guidelines.
"Certainly doctors have biases, but you can deal with those biases by having guidelines and having them reviewed externally," he said.
The efforts of Weinberger and others also pit them against the well-funded sales efforts of the medical technology and pharmaceutical industries. Companies that make everything from heart scans to drugs to artificial hips promote use of their products, increasingly through direct-to-consumer advertising.
David Nexon, Senior Executive Vice President for the trade group Advanced Medical Technology Association, discounted claims that this leads to overtreatment, saying DTC advertising does not come close to the ads sponsored by drug companies.
For years, industry could count on doctors practicing "defensive medicine," opting to order more testing rather than run the risk of missing a symptom in a patient that could lead to a lawsuit.
Patients share some of the blame for often demanding that doctors do something, anything, to make them feel better, said Shannon Brownlee, senior research fellow at the New America Foundation and author of the book "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer."
It is easy for a patient who is covered by insurance to get pulled into this "therapeutic cascade," she said. It usually starts with screening and frequently leads to more tests, and often unnecessary medical procedures and drugs.
"Sometimes people just need to be told to stop smoking, lose weight and exercise," added Resnick.
There are other factors at work too.
For example, a 50 percent increase in the number of surgeries to remove men's prostate glands in the United States from 2005 to 2008 was driven by the adoption of robotic-assisted laparoscopic prostatectomy, according to a study presented at the American Urological Association meeting last May.
Prostatectomies performed by the $1.5 million robot, manufactured by Intuitive Surgical, accounted for 80 percent of such surgeries in 2008, up from 15 percent four years earlier. The increase in prostatectomies came at a time when the incidence of prostate cancer decreased.
"When hospitals buy robots they also use them as a marketing tool in direct-to-consumer marketing. That started with the drug companies and it worked well. It's very effective," said Dr. Hugh Lavery, a urologist at Mount Sinai Medical Center in New York who authored the study.
"Surgeons are paid more to do prostatectomy than to occasionally biopsy someone. There's pressure from the (hospital) administration. They'll say, 'We just bought this thing, why aren't you using it?' It's kind of like if you buy your kid an Xbox and he doesn't use it," said Lavery.
Another example is screening for colorectal cancer.
The Centers for Disease Control and Prevention recommends three tests to find polyps or diagnose colorectal cancer: a stool test, once a year; a flexible sigmoidoscopy once every five years; or a colonoscopy every 10 years. Each test can be performed alone or in combination.
The American Cancer Society's Brawley said the $10 stool test has been shown to save lives, but in the United States, the $3,000 colonoscopy is mostly commonly used.
"Everyone is getting the expensive test, even though the cheaper test is better. But the cheaper test involves stool and no one can make money off of it," Brawley said.
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