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A coalition of doctor and consumer groups says Americans get too many unnecessary medical tests and treatments. The Choosing Wisely Initiative has just released a list of tests and procedures that they say doctors should prescribe less frequently. But some of the recommendations — for example that patients debilitated with advanced cancer shouldn’t get chemotherapy — are likely to cause concern.

We discuss the initiative, and whether patients really do want fewer tests.

Guests:
Catherine Lucey, vice dean for education at the UCSF School of Medicine, chair of the American Board of Internal Medicine (ABIM) and a trustee of the ABIM Foundation that spearheaded the Choosing Wisely Initiative
John Santa, director of the Health Ratings Center of Consumer Reports, which is partnering with the ABIM Foundation on the Choosing Wisely Initiative
David Magnus, director of the Center for Biomedical Ethics, Thomas A. Raffin professor of medicine and biomedical ethics and professor of pediatrics at Stanford University

  • Fred

    Would it not be wiser, rather than nickel and diming the patients and preventing useful tests from happening, to simply switch to socialized health care, which costs less and provides better service, rather than sending so much profits to do-little executives and investors?

    • Fred

       Typo: The second “rather than” should be “in lieu of”.

    • Actually, I come from a country that has socialized medicine (France) and the customer service is not better. (Of course, it is sometimes better on certain criteria, but definitely not across the board.) For instance, the national plan usually sets reimbursement rates too low which means long waits to see a doctor unless you buy a private supplement.

      Furthermore, setting aside harmful procedures, patients have little to no incentive to not to go through with useless procedures. After all, the cost is imposed on the system as a whole and negligible to them. So people over-consume healthcare making for very high costs.

      The way to deal with that problem is then to either make the patients bear more of the burden (at which point you’re defeating the purpose of socialized healthcare) or start rationing by banning procedures entirely or setting stringent rules for reimbursements. (which are usually fairly expensive to administrate) The problem is that rationing while influenced by informed studies such as this one is a fundamentally political process in which autistic kids will get speech therapy despite little scientific evidence that it helps while those who suffer from diseases with less well organized advocacy groups will be left with few treatment options.

    • No one is talking about preventing useful tests – just tests that end up doing more harm than good. Even if we go to socialized medicine we’d still want to reduce unnecessary treatment

  • Dave, Danville

    Good morning Michael & panel:
    It’s unfortunate that our public discourse has been so thoroughly hijacked by cynical demagoguery (“Death Panels, etc”) that common-sense initiatives — such as the ones your panel is discussing — are politically toxic.    Our gratuitous spending on unnecessary medical procedures is doing one thing and one thing only: sending a credit card bill to our kids.

    • Fred

      Our profit-based medical system will always be more expensive than socialized health care. Probably 1/3 of the costs are excessive paperwork and profit-taking.

      The USA is with every passing down more and more a country of capitalist shakedowns.

  • SteveM

    Great initiative, overdue.  What ensures that Dr.’s adopt this program and what recourse do patients or their advocates have if the Dr. is pushing treatment or giving the patient unrealistic view on their prognosis.  COPD is a condition which seems very common but there is no way to manage the end stage versus of how cancer treatment seems much better managed.  It’s high time to treat the person and the soul instead of just pushing to keep the body alive.

  • Fred

    It is the 1% that is enthusiastically opposed to socialized health care, just as they were  enthusiastically in favor of Joe McCarthy.

  • Any link between the excessive tests and treatments and geography?  : West coast vs. east coast vs. Midwest?

    • yep – check out http://www.dartmouthatlas.org/ and http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

  • Skpark

    I find the discussion by the guest doctors very one-sided.  My wife is a family practice physician who runs a rural health clinic, and her problems seem very different from those discussed.  She doesn’t get to have the conversation about waiting for a few days before prescribing antibiotics for sinusitis; her patients don’t have the money for gas to come back down to the office for a second visit if the sinusitis gets worse.

    My wife just laughed when one of your commentators mentioned that
    physicians order unnecessary tests because they get reimbursed for
    for them; she has never made a penny on a test she has ordered.
    In fact, she struggles to get tests for patients; specialists refuse to
    take uninsured, medical, and county medical patients.

    Maybe this is because the doctors developing the recommendations
    have been busy treating the 80% of us with insurance and not the 20%
    of the population that does not.

    • As much as it doesn’t make sense to forget about the 20% without insurance, it also makes a lot of sense to focus on the 80% with insurance who use a lot of healthcare and drive the costs up for everyone, including the 20% without healthcare.

  • The problem is the third-party payment system which discourages risk-management. I recall a study where patients were provided with free healthcare, classical health insurance or a stipend to self-insure. The healthcare expenditures varied widely, but there was not much difference in health outcomes. This supports the idea that if patients don’t see the cost, they will spend less carefully.

    More anecdotally, my wife recently experienced chest pains. We rushed to the ER and after a couple tests, we had a good idea that it was highly unlikely to be a heart attack. But hey, our health insurance plan meant the ER was a $100 all you can eat buffet. So when the doctors offered to spend some 10-20k of the insurance company’s money on harmless tests that would not tell us much but would make us feel better, (not worded that way) we said: “Why not?” [Update: Of course, that behavior in the aggregate raises prices on our premiums. So we did pay for this just not at the point of sale.]

    We need to stop encouraging third-party payments and let patients see the trade-offs in the expenditure of resources and their benefits.

  • Mej1928

    Thank you, Michael, for a very important discussion.

  • Nick Anton MD.

    With a single-payer ( improved Medicare-for-all) and a delivery system that moves toward integrated care and away from fee-for service payments such recommendations while important now would be a part of the system which would incorporate evidence-based medicine (which this )!!! 

    Nick

  • vc56

    I agree that unnecessary tests are ordered , however some of it is patilent driven.   Framing healthcare as a market place and patients as consumers lends itself to the demand for “Products” that consumers find listed on the internet.
     To the pint that fee for service drives tests, doctors are not allowed by law to own labs etc,. I  think ilt is more related to doctors need to see more patients to make the same ioncome and as the office visit has decreased from 30 to 15  minutes or less, there is less time to listen to the patient and evaluate what is needed and more for  shotgun approach of looking for anything and then working up is abnormal.  For example if a patient presents to a GI specialist with complaints they are scoped, an invasive , expensive procedure and if it is all negative the patient is sent on his or her way still with symptoms.
     
    Dr C

    • ‘Framing healthcare as a market place and patients as consumers lends itself to the demand for “Products” that consumers find listed on the internet.’

      And yet, in other markets that problem doesn’t seem to come up much. Why do you think that is?

      • vc56

        It is probably due to many factors. You could cite pharma, and direct to consumer advertising for instance. People are aware of medications for various illnesses and therefore want to know if they have it. They are worried and usually well. They doctor shop and insist this is why they have insurance. The market doesn’t particularly sell wellness at least in terms of prevention; most insurances do not pay for a preventative exam or vaccines for adults. Take diabetes it can. E reduced by diet and exercise or fixed by a pill, which one has full page color ads in your magazines. If you need the meds for diabetes the easy to use insulin pens are expensive and covered by some insurance quick leaves out the group that is underinsured or on Medicare. This is where disparities in healthcare shines. The people who are most in need have to use larger needles, with separate vials of insulin and an older inferior firm of insulin. They are set for failure and thus cost the system yaddy yaddy yah they are not the target market Sorry for the soapbox

        • Many of these factors are also present in many other markets though. Direct to consumer advertising and the promise of a quick fix for whatever are common across the board. I think the biggest difference is the third-party payment system. I may be subject to constant advertising for new cellphones and computers, but the fact that I have to pay for it means I have to take a step back and make a cost-benefit analysis. But in healthcare, the cost for a lot of stuff is hidden behind insurance premiums. As a result, people just don’t have to take that into account which means a lot of stuff that’s only slightly useful (including simply making the patient feel slightly better about their condition) gets provided in much larger quantities than it should.

          • vc56

            I agree if a person is told they will bear the cost their “need” to get a test is lessened. A difference in advertising too patients is that you appeal to their fragile self, fear or death or physical limitations. Many of the things we buy are not basic necessities like food water and shelter. Healthcare should be basic and have a pay structure that credits the primary care providers as the top in the field flipping the pyramid structure of specialists on top upsidedown. In general, the specialist will get paid more for spending less time with a person an order more expensive tests and use high priced medications. Primary care doctors who truly have a passion to take care of people are a dying breed. In order to improve our system we use more technology but never say when it is not appropriate to use it for example at the extremes of our life span.

  • The words “ration” and “rationing” are really mis-used and being used recklessly by Tea Party people and Republicans.  If only they would look up the word in any dictionary.  To “ration” means to limit the distribution of a SCARCE resource during difficult times (e.g. famine, war, natural disasters, etc.)  
    Expensive medications and procedures are certainly not scarce resources.  Pharma companies will gladly supply you plenty if you can show them you got money.  Mis-using the English vocabulary certainly shows these opponents are ignorant and not very bright.

  • OldVet

    I have become aware that there are a few individuals that are extraordinary at diagnosis.   I wish there were such individuals available who could ‘bat cleanup’ as opposed to being shuffled from specialist to specialist which is the epitome of wastefulness.   Why not cherish diagnostic ‘golden gloves’?

    One might propose that acupuncture diagnosis be included which is both non-invasive and economical.   The objectification of symptoms as some latin named ‘thing’ is so different from an individual discovering how the body is requesting what must be changed in the life.   We are not cars.

    The doctor from Phoenix raised a systemic flaw.  The practitioner must be distracted by looking up the system instead of practicing medicine with a patient one hundred percent.  With this divided awareness is it any wonder that doctors do not listen?

    It is amazing how many fewer secretaries one experiences when getting medical treatment in a foreign country.  Almost all of those are single payer.

    Half the distraction, one sixteenth the paperwork, half the cost resulting in longer lives, is the service model of medicine called single payer.  Making profit off of the sick and injured erodes our morality and divides the attention of the practitioner.

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