It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.
The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful.
So begins Dr. Atul Gawande’s recent essay in The New Yorker, which I have chosen as this week’s Reading.
It asks a simple question: what can we do about this?
Dr. Gawande, a general surgeon at Brigham and Women’s Hospital, is a prolific writer; he is a frequent contributor to The New Yorker and has penned several bestselling books, including Being Mortal and The Checklist Manifesto.
In this piece, Dr. Gawande focuses on overtreatment. Indeed, the title is a good summary: “Overkill.”
This essay may seem like an unusual choice for a Reading. It’s written by an American for an American audience and considers a very American topic: American health care – an article that seems so foreign to our Canadian eyes, with mention of Medicare, the Affordable Care Act and Medicare HMOs. (For those readers who don’t spend their Sunday afternoons mulling health-care policy, Medicare is the federal program that covers Americans 65 and over, the Affordable Care Act is the landmark legislation signed in to law by President Obama in 2010 and Medicare HMOs are plans within Medicare run by private companies to hold down costs.)
But Dr. Gawande’s writing is about a problem faced by health-care systems across the west – the push to get more value for money. It does not directly speak to psychiatry, but speaks to the larger system and is thus relevant if you treat people with cardiomyopathy or Capgras Syndome. (That said, I’ll delve into the psychiatric perspective in a moment.)
Here’s the link:
[Because of browser issues, try copying and pasting this link if it doesn’t work.]
Dr. Gawande notes a couple of studies on overtreatment:
· Back pain. When back pain is not accompanied by neurological symptoms, there is limited evidence for surgery. In fact, there is limited evidence for imaging. Yet, “one study found that between 1997 and 2005 national health-care expenditures for back-pain patients increased by nearly two-thirds, yet population surveys revealed no improvement in the level of back pain reported by patients.”
· Low-value care. Researchers drew up a list of 26 tests and treatments with limited benefit – such as an EEG for an uncomplicated headache. “In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.”
The essay highlights McAllen, Texas, a border town. McAllen is demographically similar to El Paso, another Texas border town. Both struggle with poverty. Both are touched by illegal immigration. But, amazingly, as of six years ago, El Paso had half the per-capita Medicare costs of McAllen. This was the basis of Dr. Gawande’s widely discussed essay in The New Yorker, published in 2009. (Though his earlier piece is worth reading, it’s not essential reading in order to understand “Overkill.”)
The reason? Dr. Gawande talks about experiments that have strengthened primary care, making it easier for physicians to manage chronic diseases like diabetes. At the core of the experimentation: “bonuses for higher patient satisfaction, reducing hospital admissions, and lowering cardiology costs.”
Dr. Gawande describes a physician working with a Medicare HMO. In the past, Dr. Osio would have seen a patient with very high blood sugar, then sent him to the Emergency Department for care – at incredible expense. But if this episodic care would have resolved the crisis, it would have left the patient still fundamentally the same: an uncontrolled diabetic. Writes Dr. Gawande:
But now WellMed gave Osio bonuses if his patients’ diabetes was under better control, and helped him to develop a system for achieving this. Osio spent three-quarters of an hour with the man, going over his pill bottles and getting him to explain what he understood about his condition and how to treat it. The man was a blue-collar worker with limited schooling, and Osio discovered that he had some critical misunderstandings.
This is an American piece but the ultimate recommendations – the need for better primary care and experimentation with “pay-for-performance” (to use the American term) – are relevant north of the 49th parallel.
But is this piece relevant to those of us in psychiatry?
After all, our patients typically don’t face overtreatment but undertreatment. A Statistics Canada survey suggests that just one in three Canadians with a mental illness gets the care that they need. We can debate that stat, but this much is clear: patients with mental health problems face major hurdles in getting care: stigma, wait lists to see specialists, uneven availability of psychological interventions. Dr. Alex Langford, a British psychiatrist who writes a lively blog, recently wrestled with the issue of health-care overtreatment.
We need to keep things in perspective. Unlike most other medical specialties, psychiatry faces the paradox that though we can prune a few treatments back as unhelpful, our main problem is that we’re vastly undertreating most people.
In rebuttal, I’ll quote Dr. Gawande in defending Dr. Gawande:
Unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative.
In psychiatry – with few resources and such need – we should be extra diligent in seeing that health-care dollars aren’t misspent on unnecessary tests and medications. We could push further with this thinking: it is incumbent on us to ensure that the delivery of care is done efficiently and effectively, getting as much value as possible from the few dollars available.
Continuing the theme of physician payment and historical bias, North York General Hospital’s Dr. Thomas Ungar notes that physician compensation is biased towards procedures and against non-procedure-based care (like mental health).
The issues here are complex and I do note that Dr. Ungar’s description is a bit simplified given that the fee schedule in Ontario – like other jurisdictions in Canada – has changed in recent years to address “relativity” (by way of disclosure: I sit on the OMA Section on Psychiatry Executive). Still, this piece is worth consideration.
“The Cost Conundrum,” Dr. Gawande’s piece on McAllen can be found here:
Thanks to Drs. David Goldbloom and Mark Fefergrad for their suggestions.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.