Monday, June 07, 2010

More on our too high health care costs....

Today's Post: Monday, 6-7-2010

Just last Friday we suggested that throwing two drugs at slightly but undesirably high blood sugar was a symptom of why medicine in the United States tends to cost more and deliver lower health results than it should.

Such readings ARE diagnostic of a problem that may get far worse if not reversed. But removing the likely two causes, ingesting health harming foods and drinks and NOT getting regular exercise will provide better protection, and incur lower medical costs including removing the need to treat the damage caused by the side effects of the two drugs.

Since then a very similar story came out suggesting that this tendency to overdo things that cost more and often either fail to improve things or make things worse is far more wide spread.

The examples in the story make it clear that we have not been careful enough in using and evaluating tests that produce false positive danger signals and in using risky or damaging X-Rays and CAT scans in a attempt to be more careful than is necessary to avoid 100 % of the risks.

Here’s a bit from this story and my comments.

“Overtreated: More medical care isn't always better

WASHINGTON AP Monday, 6-7-2010

By AP Medical Writer Lauran Neergaard & other contributors.

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.

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.”

“…. overtreatment, is a big contributor to runaway health care costs.”

“ “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. “

“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.”

“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.

“This summer, the journal Annals of Internal Medicine begins publishing American College of Physicians' guidelines for "high-value, cost-conscious care." “

“"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…..”

X* X* X* X*X

There was some good news in the article too. Some people now are beginning to turn down painful or harmful tests and procedures – which also cost LOTS of money -- for people who are unlikely to benefit from them and are in the last year or so of their lives.

They also noted that a European test that may remove many of the false positives current monitoring of fetal heart beat has generated exists and may be put into widespread use here. It would also help to have some common sense and knowledge applied even before that.

In women who are healthy and attended by competent midwives or nurse midwives and who want to give birth normally or without large extra and avoidable expenses, 5 to 10 % of births require C-sections. This means that the 20 to 55% C-section rate in most hospitals today is both avoidable and is massive overtreatment.

Why not have a nurse midwife or obstetrician listen to the baby’s heart and its speed if this device with its high false positive rate suggests a problem? That way if the problem is NOT severe or lasting, an unneeded C-section could be avoided. And, where it IS needed, it may be possible to do it more quickly.

The article doesn’t say so. But many C-sections are cause by heavy overuse of pitocin or at higher doses than necessary. This drug speeds and strengthens contractions but can force the baby into muscles that are not relaxed or opened enough yet and constrict the baby’s access to blood flow through the placenta thereby causing the problem the C-section is then needed to correct. Guidelines to end this practice totally when it is not medically necessary would cut C-section rates in half or more by itself from the reports I’ve read.

The over use of X-rays and CAT scans is a problem I recently experienced personally and quite recently.

I had a larger dinner than usual and most unfortunately found that the very bad cough I had from a bad cold or flu caused me to cough so hard that I developed a very small hernia type problem in my abdominal wall.

It was definite that something had pushed through that should not have. So, to be sure I didn’t get harmed by having my intestine trapped and get life threatening complications, I went to the emergency room.

The doctor there said that because it was so tiny and had also very little pain associated with it or none, that it was most likely that I had only pushed a bit of the “omentum” or fatty layer around my abdomen into that space, that it might well resolve on its own and was safe to leave alone.

However, he said that he would like to have me X-rayed to be sure that I had no bowel caught in it.

That may have been a good call. But the radiation tech doing the X-ray thought that the doctor had also wanted my genital area X-rayed which clearly was either false or foolish. Because by this time I was punchy from lack of sleep, I failed to demand that he provide that area a lead apron. The X-ray of the area where the problem was and four to five and a half inches above and below it, may well have been correct; but the 6 to 14 inches clearly was not.

And, since that was to rule out a problem that the doctor had said was probably not there, it certainly was not necessary.

However, that’s where the story gets really bad. Given the trouble free several hour time interval by the time the doctor saw the X-ray, unless it clearly showed a problem, the chances of there being one was less than one in 10,000 I’d guess.

The doctor couldn’t tell from the X-ray he saw. But instead of going on the basis that he likely WOULD have seen evidence of a problem if there was one and the fact that I had no pain or other indication of such a problem in the two or three hours all this took, and telling me what to do, if such pain developed, he ordered a CAT scan. Had I known then that a CAT scan uses 400 TIMES as much as an X-ray procedure or that the same radiation tech would again say I was supposed to have my genitals X-rayed again, I would have told the doctor to discuss this idea with me in considerably more detail and might well have declined it even if he still thought it was a good idea.

Was I harmed by this? Since I mostly try to avoid unnecessary X-rays, don’t smoke, and also take supplements that make cancers far less likely, possibly not.

And, my wife who I expect and want to stay married to is long past the age of child-bearing. So it may be OK that I cannot father children now if that indeed resulted.

But, this is a perfect example of this effect. It was probably medically unnecessary to do a CAT scan of the target area. And it bordered on malpractice to have included my genitals either time.

It also increased my bill from about $430 to $1280. I received no benefit or even likely benefit and may have been harmed and the bill tripled.
Given that there were NO other indications of the problem this was to test for nor did the doctor double check for them in any way, this was an increased cost that would have been far better off avoided.

So, from these two examples where I know something of the issues involved, it’s clear to me that this kind of overtreatment is a real problem with medicine in the United States and that changing to a better and better thought out system for such medical decisions might well save billions of dollars a year.

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