The ACP Advocate Blog

by Bob Doherty

Thursday, June 3, 2010

Is "more care, newer care, and more costly care" better care?

It has become pretty much an article of faith among health policy experts that higher spending on health care doesn't always buy better outcomes.

Studies by the Dartmouth Atlas have shown that show that high-spending areas of the country often have poorer outcomes than lower spending areas, even after taking into account differences in the populations being treated. Analyses of health care in other countries suggest the same: the U.S. spends far more than other westernized countries, yet by most measures, the health of our population isn’t any better and in some cases, worse.

An ACP position paper published in the January 1, 2008 Annals of Internal Medicine put it this way:

"Health care quality and access vary widely both geographically among populations, some services are overutilized, and costs are far in excess of those in other countries. Moreover, the United States ranks lower than other industrialized countries on many of the most important measures of health. Current international comparisons of measures of health (life expectancy at birth, infant mortality, and deaths per 100 000 for diseases of the respiratory system and for diabetes) indicate that population health in the United States is not better than in other industrialized countries despite the greater U.S. expenditures."

(Full disclosure: I was a co-author of this paper, developed on behalf of ACP's Health and Public Policy Committee.)

Related, many see great promise in evidence-based medicine as being the best way to level out the variations, the idea being that if physicians and patients based treatment decisions on the best available evidence, there would be fewer differences in utilization and outcomes from area to area, and overall costs associated with over-treatment might be reduced.

The problem is that the public isn’t buying it. A new study in Health Affairs finds that much of the public holds values and beliefs that are at odds with evidence-based approach principles. Much of the public believe that all care meets minimum quality standards; that medical guidelines are inflexible; that more care, newer care, and more costly care is better. The authors write:

"For health care experts, variation - in quality among health care providers, the evidence base regarding therapies, and the effectiveness and cost-effectiveness of treatment options - is a well-established fact of the health care delivery system, documented extensively in the published literature and well understood after years of careful study. Yet such concepts are unfamiliar to many Americans and may even seem threatening, to the extent that they raise unwelcome questions about the quality of medical care that people receive."

Related, the New York Times reports today against a growing backlash against Dartmouth's study on regional variations. The reporter, after citing the arguments made by Dartmouth's critics, goes as far as to conclude that "... there is little evidence to support the widely held view, shaped by the Dartmouth researchers, that the nation's best hospitals tend to be among the least expensive."

The Dartmouth Atlas responded by saying that there were at least five factual errors, and several misrepresentations in the Times article, and that "What is truly unfortunate is that the Times missed an opportunity to help educate the American public about what our research actually shows - or about the breadth of agreement about what our findings mean for health care reform."

This brings the discussion full circle back to the public's views. I am among those of the view that the data are strong enough to suggest that higher spending doesn't always mean better quality, notwithstanding the controversy over Dartmouth's research. If we are going to as a country "bend the cost curve" - and we must - then decisions will need to be made on what treatments people will get. I would rather such decisions be made by my physicians and me - informed by the best available evidence on effectiveness, including both outcomes and cost.

But in a democratic country, such decisions can't be made without public understanding and support. As long as the public believes that more care, newer care, and more costly care is better care, then it is going to be almost impossible to get a handle on costs.

Today's question: What is your reaction to the backlash against evidence-based medicine and the studies of regional variation?

12 Comments :

Blogger w said...

"I would rather such decisions be made by my physicians and me - informed by the best available evidence on effectiveness, including both outcomes and cost."

Does this mean that you, R. Doherty want to make decisions for others, or that you as an individual patient want to discuss the pros and cons and evidence for approaches with your doctor regarding your own care?

If if means the latter, how is this different from "the [mistaken] public" you refer to that are, in fact, an aggregate of individual patients speaking with their individual doctors?

(Leave aside for the moment the problem with looking at costs when prices are largely driven by the centrally-planned Medicare fee schedule and are generally uninformed by and unresponsive to any market forces, whatsoever).

June 3, 2010 at 5:15 PM  
Blogger Steve Lucas said...

“Facts are the enemy of truth.”

Doctors and patients alike hold many truths. Unfortunately many of them are wrong. New pills are always better than old pills. More tests are better than fewer tests. The only patient cost to a test is the co-pay. Drug reps are trained medical professionals.

The facts are many older medications are very effective. Many tests carry their own set of risk. In the case of some imagining studies radiation should be a point of discussion. Time and expense to the company or insurance provider are real economic cost of a test.

Go the Health Care Renewal and type in Playboy, warning adult content. We can then discuss drug rep qualifications.

My wife and I just returned from our yearly trip to Paris. Along with the absence of drug ads there is a totally different attitude towards medicine. First, with high tax burdens people understand medicine cost them money.

Secondly, you are treated when you become ill. The doctors do what they can and you are expected to accept the outcome. There is a much greater acceptance that your life choices will affect your life outcome.

People smoke. They accept this will shorten their lives. They do not expect some government entity to come up with a magic treatment when they become ill later in life. They also understand that a reasonable effort will be made to cure them of health issues arising from their smoking, but they also understand there are limits to what will be done.

This concept permeates all of medicine. Comments have floated around that Boomers are unwilling to accept their age and infirmities I have to agree. Some how there is the belief that since we put a man on the moon we can reverse a lifetime of bad habits with a pill or treatment, if only the government will spend enough money.

The truth is this would be nice; the facts are this is not going to happen. Live with it.

Steve Lucas

June 3, 2010 at 5:40 PM  
Blogger Harrison said...

Yesterday I saw a young woman who has been taking Fosamax for 4 years. She was worried about jaw pain. She had a bone density test that put her in the osteopenia range. She had two bone density tests in four years.
She has no other meds and no other health problems.
I showed her a FRAX score calculation, and convinced her that Fosamax was of very little benefit to her. Her 10 year fracture risk was already less than 1% and reducing by half is not something that should cost much money or any side effects.
I also told her that the likelihood that this jaw pain was related to her Fosamax use was also very very small.

More care was not better care, and I think she knew that about her individual case.
Nobody did anything wrong. But with evidence she could make a decision that fit her better.

If we take the time to use evidence well, then we can get to better outcomes, and probably we can cut some costs.

But we have to be careful with guidelines.
Using PSA to screen for prostate cancer is a good example.
Urologists need PSA screening.
And increasingly they are at the forefront of robotic surgery.
Evidence can help patients make better decisions about all of this.
But if hospitals and surgery centers buy the equipment, they are gonna want to use it.
They are going to latch on to pieces of evidence that fit them.
They are gonna present the evidence in ways that create a demand.

There is a fine line between preventive medicine activities and case finding to create greater demand.

If the young doctors coming out of our medical schools choose primary care, then we will make some progress in the proper use of evidence based medicine.
If the young doctors continue to be procedure based specialists, then evidence will be used to generate revenue.

Harrison

June 3, 2010 at 6:23 PM  
Blogger Jay Larson MD said...

Quality is subjective, therefore, is difficult to define. Quality to one person may mean something completely different to another. For instance, a person may think their physician is quality physician because the physician is available to them and spends time with them. Another person may think they have a quality physician because the physician is so busy, that it is impossible to get an appointment and when the appointment arrives, it is very short.

In our society, new, shiner, bigger is considered better. Why would “quality” healthcare be any different? We will continue to pay for the newer stuff until the reality that it can no longer be afforded hits us in the face.

June 4, 2010 at 1:07 PM  
Blogger c3 said...

It will come back to "who pays". If the therapy recommended will have no meaningful benefit in terms of quality or quantity of life who should pay? Should it be the employer who has an interest in the health AND happiness of the employee or the employee him or herself who has a personal preference for new technology.

I like freedom of choice but I also like responsibility to go along with that.

Urologists need PSA screening.
Please cite study demonstrating better or longer life as a result of PSA

June 4, 2010 at 1:32 PM  
Blogger Harrison said...

To c3
Are you asking me to cite a study that demonstrates better or longer life associated with PSA screening?

My comment had to do with the urology business model.
They need PSA for case finding so as to do more procedures and potentially to advance robotic surgery procedures.

There is not a lot of consensus among guideline writers about the evidence supporting the use of PSA at all.
The USPSTF recommends against using it above age 75.
They also in their comments refuse to recommend it routinely at all. And in fact suggest that it may be not be recommended at any age.
The ACP uses language that isn't that strong.
The urologists agree that it may not be an automatic test above age 75, but on the other hand they recommend a discussion and consideration of testing in men as young as age 40.

This is an example of how evidence can be used badly.
Individual studies can be used to support whatever position you want.
And it is pretty easy to support a position of higher utilization of procedures with outcomes as measured in population terms being worse than if nothing were done at all.

I know lots of men who got treated for prostate cancer. I've known lots with metatstatic prostate cancer. It is rare that I write prostate cancer on a death certificate as a cause of death. I have only seen one man who died of an aggressive prostate cancer when he was still in his 60's and that was years ago.
I've seen at least two men die from complications following prostatectomy, and I know of a few who are hospitalized with rectal bleeding periodically because of complications from XRT.

It is at best a controversial issue.

Harrison

June 4, 2010 at 4:06 PM  
Blogger Arvind said...

Agree with Jay and Steve, as usual. When I read the Health Affairs article, I was a bit surprised at the conclusions drawn by the authors. Actually, the respondents' answers seemed quite appropriate to me. Not every intervention in medical practice can be back up by "outcomes data". Also, "better" is a poor way to describe comparison between a new and an old medication. One has to evaluate which drug provides a more desirable response to a particular condition in a particular patient at any particular time.

For a change, I actually agree with harrison with regard to the Fosamax case, even though FRAX scores are usually appropriate in a drug-naive patient.

June 4, 2010 at 9:15 PM  
Blogger c3 said...

Harrison;
Thanks for your detailed response. I would disagree with this:
this is an example of how evidence can be used badly.

What you described as how the evidence is used all seems reasonable. It would be naive for me to assume that the urologist doesn't RECOMMEND the PSA even if he/she had noted that the evidence isn't clear as to whether getting the test will likely lead to a better or longer life than not getting the test. I'm ok with that.

But what "changes" the interaction is the lack of "financial accountability" for the patient. Not to sound too glib but its similar to the choice between buying a Hyundai or a BMW. I can understand from the salesman why the BMW is the better way to go but I have to acknowledge they will both get me to and from work. So are the "extras" of the BMW "worth it" to me.

And finally:
know lots of men who got treated for prostate cancer. I've known lots with metatstatic prostate cancer. It is rare that I write prostate cancer on a death certificate as a cause of death. I have only seen one man who died of an aggressive prostate cancer when he was still in his 60's and that was years ago.

I'm not sure if you're just stating your experience or implying something about the nature of prostate cancer (slow growing) or something about the results of more aggressive screening and treatment (i.e. better outcomes)

June 5, 2010 at 11:33 AM  
Blogger k-9 said...

I appreciate what Steve Lucas said.

Working in Crit care, i often see docs and patients or their families feel that "if it can be done, it should be done". little discussion of the likely benefit, physical, emotional, or financial harms are discussed or questioned.

For the system to change, both the providers and the "public" must accept the inevitable limitations of life, the consequences of poor behaviour, and the cost of wringing out every last opportunity to "torture" a patient, both emotionally and financially, with the latest and greatest technology

June 6, 2010 at 9:39 PM  
Blogger Robert J. Sobel, M.D. said...

I am not sure a true backlash is occurring. There is an appropriate disconnect between the terms of the modern academic models and the first-hand experience of patients. Historically, especially in the recent generations of academic medical training, I believe there has been a general attempt to rise above cost considerations when outlining treatment plans. As our current rarified specialization and up-front financing of new technology has introduced wide cost differentials, cost considerations have come more to the forefront.

The fundamental problem is that the cost variation is out of the control of most physicians. The macroeconomic data that emerges from the Dartmouth Atlas appears to capture hospital phenomena, with their impressive intensiveness of care, more than the core outpatient care that should be a greater percentage of the pie.

As the SGR continues to subject physicians and ancillary testing to a cost-control structure that is not applied at the hospital or pharmaceutical level, I believe the notion of integrating the very specific roles that exist today in health care is fraught with potential downsides. It would actually be a lot easier (and substantially more effective) to manage hospital infrastructure and introduce a fee schedule for pharmacotherapy, than to bureaucratize health care even further. The dream of ACO's and guideline-driven care is a dangerous one.

Patients do not wish more manipulation than they already must endure with formularies, prior approvals, preferred providers, and in-network/out-of-network status. Medical decisions remain personal and nuanced. The more information on the relative values of various interventions, the more the best practices will be adapted. The continued claim that this is a difficult obstacle is an erroneous assumption based upon the appropriate stubborness of the experienced clinician. In just the last 10 years, a guideline disciple would have gone back and forth on pre-operative beta-blockade, homocysteine lowering, and hormone replacement. While many of us did adjust our efforts, the conservatism of caring for someone longitudinally is a reflection of our need to maintain credibility in an ever changing and ever more complicated diagnostic and therapeutic playing field. Let us take advantage of this crucial core while we try to bend the cost curve. It would take a lot of physician squeezing to make up for the cost of the new frontiers in health care and their absurd pricing.

June 7, 2010 at 8:41 AM  
Blogger Robert J. Sobel, M.D. said...

I am not sure a true backlash is occurring. There is an appropriate disconnect between the terms of the modern academic models and the first-hand experience of patients. Historically, especially in the recent generations of academic medical training, I believe there has been a general attempt to rise above cost considerations when outlining treatment plans. As our current rarified specialization and up-front financing of new technology has introduced wide cost differentials, cost considerations have come more to the forefront.

The fundamental problem is that the cost variation is out of the control of most physicians. The macroeconomic data that emerges from the Dartmouth Atlas appears to capture hospital phenomena, with their impressive intensiveness of care, more than the core outpatient care that should be a greater percentage of the pie.

As the SGR continues to subject physicians and ancillary testing to a cost-control structure that is not applied at the hospital or pharmaceutical level, I believe the notion of integrating the very specific roles that exist today in health care is fraught with potential downsides. It would actually be a lot easier (and substantially more effective) to manage hospital infrastructure and introduce a fee schedule for pharmacotherapy, than to bureaucratize health care even further. The dream of ACO's and guideline-driven care is a dangerous one.

Patients do not wish more manipulation than they already must endure with formularies, prior approvals, preferred providers, and in-network/out-of-network status. Medical decisions remain personal and nuanced. The more information on the relative values of various interventions, the more the best practices will be adapted. The continued claim that this is a difficult obstacle is an erroneous assumption based upon the appropriate stubborness of the experienced clinician. In just the last 10 years, a guideline disciple would have gone back and forth on pre-operative beta-blockade, homocysteine lowering, and hormone replacement. While many of us did adjust our efforts, the conservatism of caring for someone longitudinally is a reflection of our need to maintain credibility in an ever changing and ever more complicated diagnostic and therapeutic playing field. Let us take advantage of this crucial core while we try to bend the cost curve. It would take a lot of physician squeezing to make up for the cost of the new frontiers in health care and their absurd pricing.

June 7, 2010 at 8:47 AM  
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June 8, 2010 at 1:34 PM  

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Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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