As mentioned recently, the issues of overdiagnosis and overtreatment are in the spotlight, with the Choosing Wisely campaign recently launched in the US, with the backing of medical societies and consumer groups, urging doctors and patients to identify tests and treatments that may not be necessary.
Overuse of healthcare also received star billing at the recent Association of Health Care Journalists conference in Atlanta, thanks to the keynote address from oncologist Dr Otis Brawley, the chief medical and scientific officer of The American Cancer Society, and author of How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.
He said healthcare would not improve until the broader population demanded that doctors base their practice on science, and gave the history of prostate cancer screening and bone marrow transplants as two examples for concern. “Doctors tend to confuse what they believe with what they know,” he said. “We need the sceptical, educated consumer.”
The benefits of medicine more broadly were often exaggerated, he said, while the public needed to accept that “death is a part of life”.
Brawley also called for a greater focus on prevention, and said that at present doctors who do interventions and procedures get a lot more money than they should, in contrast to those involved in talking and counselling. The recommendations of the Choosing Wisely campaign would decrease doctors’ incomes “and that may be a good thing overall”, he said. (You can watch the full presentation in the link at the bottom of this post).
Meanwhile, Dr Tim Woodruff, vice president of the Doctors Reform Society, writes below that structural change is needed to address overutilisation. Moving healthcare to a team-based salaried service would not only help tackle overutilisation, but would facilitate wider patient and consumer involvement, and could help address “the gross inequity of access which currently exists”, he says.
Tackling overutilisation of health services
Dr Tim Woodruff writes:
The consequences of over diagnosis, over investigation, and over treatment in health care systems has dire consequences not only for those individuals subjected to such treatment, but to the rest of the population who look to their health care system for appropriate treatment or management.
Thus, as has been said by others, instead of rational use of resources, many are subjected to rationing because politics limits the amount of public funding available and income levels prevent many accessing private care. As one would expect, rationing predominantly affects those who are not rich enough to use the private system or travel from areas of workforce shortage to areas of oversupply.
One could look at the bright side of rationing. If you have to wait 2 years for a knee arthroscopy in the public system the problem may well have settled down and you have avoided the small but definite risks of an arthroscopy. If it takes 3 months to see the urologist about your modestly elevated PSA (a disputed screening test for prostate cancer), the repeat test may show the level is lower and you may avoid immediate consideration of potentially dangerous interventions.
The dark side however is that patients face copayments they can’t afford or they simply can’t find the health care provider they need in their location.
The Commonwealth Fund survey from 2010 found that 22% of Australians didn’t see their doctor when ill or didn’t do tests recommended or skipped drugs or didn’t fill out prescriptions because it cost too much. They also face waiting times of years to access public hospitals for elective surgery eg hip replacement.
One issue this raises is the possibility of addressing the wasteful and dangerous over utilisation of resources and directing them appropriately to deal with these equity issues. That really depends upon how the issue of over utilisation is addressed.
Over utilisation takes many forms. There is the medicalisation of the normal range of human behaviour which then requires treatment. Although there are some examples of this being due to a non profit based genuine scientific and human interest in improving health, it is seldom the whole story and even when that is the basis for such interest it is frequently consumed by financial interest. To arrest that process requires arresting the profit motive in health servicing. A tall order in societies which are increasingly accepting that health servicing is an industry rather than a system for delivering health care as needed.
There is, however, another form which is prominent in overutilisation. It is a belief that one must be able to act to improve the situation. It includes a belief that as a highly trained professional, the skills one has should be able to offer something to address the problem with which the patient presents. Thus, a doctor trained to prescribe a medication for most problems may expect to do just that for problems for which medication is inappropriate. A surgeon trained to do an operation for most knee problems he sees will look to do just that even in the face of suggestive evidence that it won’t help in the long term.
It includes a conscious and unconscious link to the profit motive. But such a link is often not apparent. It involves providers, doctors and others, who work long hours responding to needs, expecting to be well remunerated, but often too dedicated to doing their work to enjoy the financial rewards, believing that what they are doing is what is required for the benefit of their patients. Some may question their own practices but when surrounded by other doctors who are much more interventionist, they feel they are demonstrating restraint.
The ever present uncertainty of data and the difficulty in interpretation of data means that clinical practice cannot be determined by the science. The science is a guide only. Every day doctors who look very critically at the data are faced by patients who do not fit into the clinical trial data which guides them. Extrapolating from clinical trials is inevitable for specialists despite a wish to rely on good data. We check with colleagues. What would you do in this situation? Teenagers are not the only group in our society who are subject to peer influence.
For those who don’t have expertise in a particular area and rely on experts to guide their management, another layer of uncertainty descends. How independent is the expert? How much does the expert’s involvement with the drug or device industry affect his/her opinion? How much does the expert’s own research efforts influence his/her opinion? For most doctors the answer to that question is often just a matter of judgement based on personality, beliefs, and perceptions. Drug companies seek out convincing key opinion leaders to influence this process.
This is not a problem of profit driven doctors. It is a system problem. If health care is an industry, profit will dictate its processes and outcomes. If health care is an industry with very large players, patients will suffer from over and under servicing. If healthcare is an industry of small businesses (which has been the case previously in Australia), it has some chance of avoiding such problems because providers have some control but can still be heavily influenced by external forces such as pharmaceutical companies and key opinion leaders.
If health care is a service which is centred on patients, it promotes the aspirations of the majority of health care professionals to provide a service rather than succumb to the necessities of the business ethic.
Until it is recognised and accepted that healthcare as an industry will drive over utilisation to the detriment of all except the providers, only minor control of this problem can occur.
Until it is accepted that fee for service funding is a barrier to team based care and consumer participation the scene is set for a continuation of over utilisation in its various forms. Education can help to a limited extent but works so slowly as evidenced by the lag time between the recognition that antibiotics are not needed for most ‘colds’ or that tonsillectomies were not needed in most 4-6 year olds and the appropriate change in practice to limit antibiotics for the former and stop dangerous surgery for the latter.
Experience in the United States that healthcare costs can be controlled by moving to a team based salaried workforce eg Mayo Clinic, Kaiser Permanente, without any evidence of decline in quality and indeed suggestions of better outcomes, is supportive of the concept of moving away from fee for service provision of services.
The question of private versus public funding becomes important when looking at the accessibility of services. In Australia, the debate is very different because funding remains predominantly public but team based salaried approaches are largely restricted to the public sector where hospitals are the prime example.
If such resistance to team based salaried service were overcome, the potential exists for a reduction in over utilisation. The additional benefits would be huge. Patient/ consumer involvement would be facilitated by such structural change. If funded publicly, such services could be funded on the basis of measured need, thus addressing the gross inequity of access which currently exists.
Savings from over utilisation could be used to build such services. Team based service providers would be in a position to advocate around the social determinants of health, especially as it would become more apparent that inequalities in health outcomes cannot simply be addressed by ensuring access to services.
The increasing awareness of and education about overutilisation is welcome and necessary, but without structural change to how services are delivered and funded, its impact will be small and gradual.
• Tim Woodruff is vice president, Doctors Reform Society
Dr Otis Brawley’s presentation to health journalists
This presentation is worth watching. Overuse of healthcare can also have adverse consequences for clinicians: Brawley describes how he was traumatised as a young doctor by an experience involving aggressive intervention with a dying cancer patient.
Declaration: Melissa Sweet is currently attending a meeting on overdiagnosis convened by Bond University Centre for Research in Evidence-based Practice, for which her travel and accommodation expenses have been paid.