* U.S. doctor group with broad reach tackles overtreatment
* Government to lean more on providers to cut the cost of
* Economists question physicians' conflicts of interest
By Debra Sherman
CHICAGO, Feb 16 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
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
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
"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.
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.