When More Medicine Is Less
A Dartmouth study finds a greater risk of death among patients treated in high-cost hospitals and clinics -- and highlights conflicts of interest
COVER STORY
By John Carey
BusinessWeek, MAY 29, 2006
Getting more medical care, and paying more for it, can actually make your health worse. That's the paradoxical conclusion of Dartmouth Medical School's Dr. Elliot S. Fisher. He found that the amount spent per person on health care varies dramatically in different parts of the country. Southern California is high cost, for instance, while Northern California is low cost. Spending is high in the Boston area, and low in Western Massachusetts and Minnesota.
Fisher originally expected to find that people in areas with more healthcare would be healthier and longer-lived. The opposite was true. "If anything, it looks like there is a substantially increased risk of death if cared for in high-cost systems," he says. The reason: The additional tests and procedures in the high-cost areas bring more risks than benefits. "A large portion of those extra costs are due just to proximity to health care," says George Bennett, CEO of Health Dialog Analytic Solutions, which tries to get unbiased information to patients. "Not all those expenditures are optimal or even appropriate."
Why does this happen? Clearly, one huge underlying cause is money. The way the U.S. health-care system is structured offers doctors, hospitals, and companies enormous financial incentives to provide more and more care. Surgeons will get paid if they do a bypass operations, insert ear tubes in children, or take out a prostate. If they recommend waiting or doing drug therapy instead, there's no payday.
"You get paid for operating and not paid for not operating," says Dr. Jack Paradise, a professor of pediatrics and otolaryngology at the Pittsburgh School of Medicine and Children's Hospital of Pittsburgh. "Conflict of interest is hard to rule out."
POTENTIAL CONFLICTS. Similarly, hospitals get higher revenues if they put more patients in their new catheter labs or operating rooms. This isn't to say financial considerations outweigh medical choices. But studies have shown wide variations in the amount of care among hospitals -- and again, more care doesn't bring better results.
Researchers at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School have looked in detail at what happens in the last six months of life at 77 top hospitals in the U.S. The results were startling: The average number of days spent in the hospital during the last six months of life was 10.1 days at Stanford University hospital compared to 27.1 days at New York University Medical Center. The average number of doctors visits ranged from 17.6 to 76.2, with NYU at the top.
Yet there's no evidence that the more intensive care brings better outcomes or quality of life. In fact, the researchers suggest, the opposite is true. "The problem is not underuse in low-rate regions and hospitals, but overuse and inefficiency in high-rate regions," concludes Dr. John E. Wennberg, professor of medicine and director of Dartmouth's Center for the Evaluative Clinical Sciences.
The potential conflicts of interest are even starker with drug and medical device makers. The pharmaceutical and device industries are, after all, businesses. Like any businesses, they would be remiss in their duty to shareholders if they didn't try to sell as many of their products as possible.
GOVERNMENT CONCERN. Health care is different from, say, selling cars. No one is hurt if people buy one car over another, or more cars than they need. But for all their benefits, drugs have dangers. Taking the wrong one, or the wrong combination, or too high a dose, or one that's not needed, does hurt people -- and raises health care costs unnecessarily.
That's why the Food & Drug Administration puts curbs on the marketing practices of companies. But because of the huge amounts of money that come with increased sales, they have every incentive to push the envelope when it comes to marketing. As a result, they often work to turn ordinary conditions, like jittery legs, into "diseases" that need treatment (see BW Online, 05/08/06, "Hey, You Don't Look So Good").
They woo doctors with free samples, gifts, trips, and other enticements to prescribe more drugs and use additional devices. A recent lawsuit, for instance, accuses Medtronic (MDT ) of handing hundreds of thousands of dollars for minimal work to prominent back surgeons who are in a position to boost use of the company's spinal-implants. Medtronic spokesman Rob Clark notes that these are allegations. "We do not tolerate any kind of conduct that is unethical...or violate the law," he says.
BOTTOM-LINE BIAS. In another case, Warner-Lambert, a part of Pfizer, (PFE ) was ordered to pay $430 million after pleading guilty to charges of illegally marketing its epilepsy drug, Neurontin, for unapproved uses. The company aggressively pushed the drug for conditions like bipolar disorder, back pain, and headache -- for which there was little or no evidence of effectiveness.
The marketing campaigns, which included trips and big "speaker" fees to doctors, turned the drug into a blockbuster, with billions of dollars in sales per year. But while the practices fattened the company's bottom line, many patients may have been hurt by unnecessary use of the drug, which lawsuits allege can cause suicidal thoughts, tumors, and convulsions.
These powerful financial incentives make it that much harder to get the right treatments and the right amount of care to Americans.
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Thursday, October 19, 2006
Medicine's Industrial Revolution
Medicine's Industrial Revolution
COVER STORY
By Howard Gleckman, with John Carey
BusinessWeek, MAY 29, 2006
Sometimes medicine performs just as it should. Vaccines have banished smallpox. Surgery can cure early-stage colon cancer. But the disturbing truth is treatments that are proven to work reach only about half of the Americans who need them, according to a series of studies by RAND Corp. And in hospitals, simple measures that protect patients' lives are often hard to implement.
Hygiene is a good example. For 150 years we have known that doctors with unwashed hands pass infections from patient to patient. The Centers for Disease Control & Prevention figures that 80% of hospital-acquired infections are transmitted this way, costing billions of dollars annually to treat and killing thousands of people.
With this in mind, the University of Pittsburgh Medical Center's Presbyterian Hospital installed alcohol-wash dispensers in every room and allowed nurses to ban doctors who don't wash up from entering patients' rooms. Yet more than one-quarter of UPMC's doctors still haven't gotten the message, says Chief Medical Officer Loren H. Roth. Things have improved in recent years, "but a lot of physicians and residents are still not complying," he says.
One major cause for such huge gaps in care is that financial incentives can be skewed. Insurance companies, which have learned that high infection rates cost them money, are beginning to provide bonuses to encourage hospitals to make big improvements. Highmark Inc., which operates the Blue Cross/Blue Shield plans in Pittsburgh, will give UPMC $10 million this year for lowering infections.
But doctors don't have the same incentives. They are usually not hospital employees and are paid based on the number of patients they see and procedures they do. Repeatedly stopping to wash up may slow them down and cost them money. That has hospitals such as UPMC as well as private insurance companies and Medicare scrambling for new ideas. "How do we align incentives so we pay more for prevention than for solving the disaster after it happens?" asks Donald R. Fischer, chief medical officer at Highmark.
UPMC's Roth says that improving the quality of care may also mean challenging a bedrock belief: that each patient is unique and that doctors must bring individualized judgment to each case. This view "has a kind of appeal to it for both the profession and patients," says Roth, "but it is not so." Most illnesses and injuries can best be treated by standardizing care, he argues. The goal is to "industrialize every process we can."
This idea horrifies some doctors, but businesses and insurance companies, who pay many of the bills, are cheering Roth on. "We know if you take beta blockers, you are much less likely to have a heart attack," explains Helen Darling, president of the Washington-based National Business Group on Health, which represents major employers. "We can reward you for meeting those standards."
Independence Blue Cross has gone a step further. It gives physicians lists of members with chronic conditions such as diabetes and asthma. The list includes the recommended treatments and tells who has received them. "Then when a patient shows up, the missing services can be provided," explains Dr. I. Steven Udvarhelyi, senior vice-president at the insurer. Doctors, who were leery at first, have embraced the plan.
Of course, you have to get people into physicians' offices. To do this, several health plans and companies have teamed up with Health Dialog Analytic Solutions, which identifies employees or plan members with the greatest needs and reaches out through phone calls and mailings. "The touch is very soft," says Joe Checkley, director of global benefits at American Standard Cos (ASD ). "It's saying: 'Here are some tools for you, and what can I do to help?"'
The early results are good. At Independence Blue Cross, with about 2 million members, "we know that the program overall reduces medical costs by about 2%," says Udvarhelyi. "That's for the entire population, not just the people that we touch. For them the reduction is orders of magnitude larger." With efforts like these, treatments that do work are now getting to more of the people who need them.
Read article at the original source
COVER STORY
By Howard Gleckman, with John Carey
BusinessWeek, MAY 29, 2006
Sometimes medicine performs just as it should. Vaccines have banished smallpox. Surgery can cure early-stage colon cancer. But the disturbing truth is treatments that are proven to work reach only about half of the Americans who need them, according to a series of studies by RAND Corp. And in hospitals, simple measures that protect patients' lives are often hard to implement.
Hygiene is a good example. For 150 years we have known that doctors with unwashed hands pass infections from patient to patient. The Centers for Disease Control & Prevention figures that 80% of hospital-acquired infections are transmitted this way, costing billions of dollars annually to treat and killing thousands of people.
With this in mind, the University of Pittsburgh Medical Center's Presbyterian Hospital installed alcohol-wash dispensers in every room and allowed nurses to ban doctors who don't wash up from entering patients' rooms. Yet more than one-quarter of UPMC's doctors still haven't gotten the message, says Chief Medical Officer Loren H. Roth. Things have improved in recent years, "but a lot of physicians and residents are still not complying," he says.
One major cause for such huge gaps in care is that financial incentives can be skewed. Insurance companies, which have learned that high infection rates cost them money, are beginning to provide bonuses to encourage hospitals to make big improvements. Highmark Inc., which operates the Blue Cross/Blue Shield plans in Pittsburgh, will give UPMC $10 million this year for lowering infections.
But doctors don't have the same incentives. They are usually not hospital employees and are paid based on the number of patients they see and procedures they do. Repeatedly stopping to wash up may slow them down and cost them money. That has hospitals such as UPMC as well as private insurance companies and Medicare scrambling for new ideas. "How do we align incentives so we pay more for prevention than for solving the disaster after it happens?" asks Donald R. Fischer, chief medical officer at Highmark.
UPMC's Roth says that improving the quality of care may also mean challenging a bedrock belief: that each patient is unique and that doctors must bring individualized judgment to each case. This view "has a kind of appeal to it for both the profession and patients," says Roth, "but it is not so." Most illnesses and injuries can best be treated by standardizing care, he argues. The goal is to "industrialize every process we can."
This idea horrifies some doctors, but businesses and insurance companies, who pay many of the bills, are cheering Roth on. "We know if you take beta blockers, you are much less likely to have a heart attack," explains Helen Darling, president of the Washington-based National Business Group on Health, which represents major employers. "We can reward you for meeting those standards."
Independence Blue Cross has gone a step further. It gives physicians lists of members with chronic conditions such as diabetes and asthma. The list includes the recommended treatments and tells who has received them. "Then when a patient shows up, the missing services can be provided," explains Dr. I. Steven Udvarhelyi, senior vice-president at the insurer. Doctors, who were leery at first, have embraced the plan.
Of course, you have to get people into physicians' offices. To do this, several health plans and companies have teamed up with Health Dialog Analytic Solutions, which identifies employees or plan members with the greatest needs and reaches out through phone calls and mailings. "The touch is very soft," says Joe Checkley, director of global benefits at American Standard Cos (ASD ). "It's saying: 'Here are some tools for you, and what can I do to help?"'
The early results are good. At Independence Blue Cross, with about 2 million members, "we know that the program overall reduces medical costs by about 2%," says Udvarhelyi. "That's for the entire population, not just the people that we touch. For them the reduction is orders of magnitude larger." With efforts like these, treatments that do work are now getting to more of the people who need them.
Read article at the original source
Medical Guesswork | A Lumpectomy May Do It
Medical Guesswork | A Lumpectomy May Do It
BusinessWeek, May 29, 2006
For Jeanine Whitney, the diagnosis of breast cancer last June was bad enough. But when her doctor told her that her best chance was an immediate mastectomy, "I cried for 24 hours. I felt that part of my womanhood would have been taken," says Whitney, who works at an air conditioner factory in Rushville, Ind. Her employer, American Standard Cos., had a program to provide workers with unbiased information about the risks and benefits of potential treatments. Thanks to the program, Whitney learned that there was no evidence that a mastectomy would have a better outcome than a lumpectomy, provided the tissue around the lump was clear of cancer. Twenty years after treatment, the outcomes were the same, according to studies. "It was a total surprise," she recalls. She requested a lumpectomy, which was carried out in July, followed by seven weeks of radiation and six of recovery. Now, Whitney is grateful that she was able to get the information she needed to buck her doctor's recommendation. If Whitney had had to make a decision without that, she says she would have "ended up in the psychiatric ward."
Read article at the original source
BusinessWeek, May 29, 2006
For Jeanine Whitney, the diagnosis of breast cancer last June was bad enough. But when her doctor told her that her best chance was an immediate mastectomy, "I cried for 24 hours. I felt that part of my womanhood would have been taken," says Whitney, who works at an air conditioner factory in Rushville, Ind. Her employer, American Standard Cos., had a program to provide workers with unbiased information about the risks and benefits of potential treatments. Thanks to the program, Whitney learned that there was no evidence that a mastectomy would have a better outcome than a lumpectomy, provided the tissue around the lump was clear of cancer. Twenty years after treatment, the outcomes were the same, according to studies. "It was a total surprise," she recalls. She requested a lumpectomy, which was carried out in July, followed by seven weeks of radiation and six of recovery. Now, Whitney is grateful that she was able to get the information she needed to buck her doctor's recommendation. If Whitney had had to make a decision without that, she says she would have "ended up in the psychiatric ward."
Read article at the original source
Medical Guesswork | Bypass That Operation?
Medical Guesswork | Bypass That Operation?
BusinessWeek, May 29, 2006
Each year doctors perform 400,000 bypass surgeries and 1 million angioplasties, where mesh tubes are placed in diseased arteries to hold them open. While most people believe that such surgery is life-saving, the available data say otherwise. Except for about 3% of people with severe heart disease, treatment with drugs alone works just as well to extend life and prevent heart attacks as surgery does.
"Cardiologists like to open up arteries," says Dr. David D. Waters, chief of cardiology at San Francisco General Hospital. "But there is no evidence that opening up chronically narrowed arteries reduces the risk of heart attack." Harvard Medical School's Dr. Roger J. Laham figures that at least 400,000 angioplasties a year are unnecessary. "I'm sure we are way overtreating our patients," he says. Surgery carries big risks, such as mental declines after bypass operations. The overuse is exacting a big toll on individual patients and the health-care system, argue such experts as Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill.
Read article at the original source
BusinessWeek, May 29, 2006
Each year doctors perform 400,000 bypass surgeries and 1 million angioplasties, where mesh tubes are placed in diseased arteries to hold them open. While most people believe that such surgery is life-saving, the available data say otherwise. Except for about 3% of people with severe heart disease, treatment with drugs alone works just as well to extend life and prevent heart attacks as surgery does.
"Cardiologists like to open up arteries," says Dr. David D. Waters, chief of cardiology at San Francisco General Hospital. "But there is no evidence that opening up chronically narrowed arteries reduces the risk of heart attack." Harvard Medical School's Dr. Roger J. Laham figures that at least 400,000 angioplasties a year are unnecessary. "I'm sure we are way overtreating our patients," he says. Surgery carries big risks, such as mental declines after bypass operations. The overuse is exacting a big toll on individual patients and the health-care system, argue such experts as Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill.
Read article at the original source
Medical Guesswork | Leave Those Ears Alone
Leave Those Ears Alone
BusinessWeek, May 29, 2006
In the 1950s, kids routinely got their tonsils taken out. Then physicians such as Dr. Jack L. Paradise of the University of Pittsburgh School of Medicine showed that the procedure brought no benefits to most children.
In a study published last August, Paradise took on another common treatment: implanting tubes to drain the fluid in children's ears -- thought to hamper hearing and slow language development. Children with fluid do tend to have more speech problems. But Paradise believes the two conditions have a common cause: poor living conditions. "Medicine is fraught with error when people assume correlation is causality," he says. So Paradise did a study of 6,000 babies. By age three, 429 had persistent fluid in their ears. Half got ear tubes, the other half didn't -- and there was no difference in outcomes between the two groups.
Paradise's advice to parents of such kids: "Don't just do something. Sit there." Many doctors still perform the surgery, however. "People are reluctant to believe our results," Paradise says. Why? "You get paid for operating and not paid for not operating."
Read article at the original source
BusinessWeek, May 29, 2006
In the 1950s, kids routinely got their tonsils taken out. Then physicians such as Dr. Jack L. Paradise of the University of Pittsburgh School of Medicine showed that the procedure brought no benefits to most children.
In a study published last August, Paradise took on another common treatment: implanting tubes to drain the fluid in children's ears -- thought to hamper hearing and slow language development. Children with fluid do tend to have more speech problems. But Paradise believes the two conditions have a common cause: poor living conditions. "Medicine is fraught with error when people assume correlation is causality," he says. So Paradise did a study of 6,000 babies. By age three, 429 had persistent fluid in their ears. Half got ear tubes, the other half didn't -- and there was no difference in outcomes between the two groups.
Paradise's advice to parents of such kids: "Don't just do something. Sit there." Many doctors still perform the surgery, however. "People are reluctant to believe our results," Paradise says. Why? "You get paid for operating and not paid for not operating."
Read article at the original source
Medical Guesswork | Curing Without Cutting
Medical Guesswork | Curing Without Cutting
BusinessWeek, May 29, 2006
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth.
Curing Without Cutting
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth."
Read article at the original source
BusinessWeek, May 29, 2006
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth.
Curing Without Cutting
Can you trust your doctor's recommendation to have surgery for an aching back? Make sure you have all the facts. Evidence says surgery does not fix the problem over the long term any better than time, physical therapy, and exercise. Indeed, says University of North Carolina's Dr. Nortin M. Hadler, pain clinics are full of people who have had back surgery and now are worse off. Geographic data suggest that such procedures may be a fad. In people with identical symptoms, operations like spinal fusion are performed 20 times as often in some parts of the U.S. as in others. 'Spinal fusion is the most variable condition in all of medicine,' says Dr. James N. Weinstein, editor of Spine magazine and chair of orthopedic surgery at Dartmouth."
Read article at the original source
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