Truth Squad: Fear-Mongers Ignore Risks

“Plan To Slash U.S. Health Costs May Be Tough Pill To Swallow” blared a headline on Investors late last week. The story begins: “When someone takes out a scalpel, it's usually going to hurt — a lot. Yet Peter Orszag, President Obama's budget director, claims the U.S. could slash $700 billion in annual medical costs without affecting quality.”

The article quotes arguments on both side of the debate, but the headline has already signaled that the story has a point of view.  And this hard-hitting quote from Greg Scandlen, head of the conservative “Consumers for Health Care Choices” at the Heartland Institute, seemed to sum up the story’s thesis: "It is often impossible to know ahead of time what is going to work and what won't. The notion that a physician should only deliver services that he knows ahead of time will work ignores real-life conditions. "It's offensive that a bean counter like Orszag should Monday-morning-quarterback physician decisions."

The truth is that Scandlen simplifies “real-life conditions” by ignoring the fact that every medical treatment carries risks as well as hope of benefits. If there were only benefits then the old-fashioned “Oh what the heck, let’s just go in there—what harm can it do?” school of medicine would make sense.
But it doesn’t. This is why patients should ask questions about the downside.

Over at Newshoggers, Ron Beasley offers an example:
“My 86 year old mother is in really good health but had started to be short of breath. They ran some diagnostic tests and discovered she had a bad heart valve. She was referred to a cardiologist who was ready to split her chest open and replace the valve. I asked him several questions:
1.   She is in relatively good health now – following the surgery will she ever recover to be as good as she was before? The answer was probably not!
2.   I told the doctor that I heard that being on a heart lung machine can have a negative impact on memory and asked him if that was true. The answer was yes, especially in older people.
3.   The next question was what will happen if the valve is not replaced? The answer was the shortness of breath may gradually get worse.
4.   I asked him if it were his mother would he suggest the surgery? The answer was NO!
“The bottom line is they were going to perform a procedure that would cost 50 thousand plus dollars that would have left my mother worse off after the surgery because Medicare would pay for it.”

Beasley tells an anecdote. The numbers tell the larger story about invasive and unnecessary heart procedures. Below, Dr. Michael Ozner, author of The Great American Heart Hoax: outlines what we know about aggressive heart procedures
More than 1.5 million angioplasties and coronary bypass surgeries are done annually in the US, which makes heart surgery among the most commonly performed surgical procedures for both men and women. Although heart surgery can be lifesaving, the truth is that surgery benefits only a small fraction of the millions of patients who undergo these operations. For the majority—an estimated 70 to 90 percent—these procedures are at best unnecessary. In fact, except for a minority of patients, bypass surgery and angioplasty have never been shown to prolong life or prevent heart attacks. And while American patients are seven times more likely to undergo coronary angioplasty and bypass surgery than patients in Canada and Sweden, the number of Canadians and Swedes who die from cardiovascular disease is nearly identical (per capita) to the number of people who die from heart disease in this country.
We’re spending billions of dollars every year on risky procedures that have never been shown to benefit the majority of patients, or make a significant difference in the overall mortality rate.
In fact, the mortality rate for bypass ranges from 3 to 5 percent. This may sound insignificant initially, but when you consider that half a million people undergo these procedures every year, 3 to 5 percent quickly adds up: to 15,000 to 25,000 lives lost a year. Additionally, an estimated 25 to 30 percent of angioplasties fail, requiring patients to repeat the procedure. And eventually many of these angioplasty patients will also require bypass surgery.
The mortality rate isn’t the only worrying statistic associated with bypass surgery. Up to 80 percent of patients may experience cognitive difficulties after surgery, something that can be especially devastating to elderly patients, who may already be experiencing problems with memory and other early signs of cognitive decline. People who undergo bypass surgery are nearly four times more likely to suffer a subsequent stroke at the time of surgery than if they had elected not to go under the knife. They are also vulnerable to post-surgical infections. Nor are coronary angioplasty and stent placement risk-free; complications include heart attack, stroke, aneurysm at the puncture site, infection, and the need for emergency bypass surgery. Contrast this with the cost of following a heart-healthy lifestyle: none!
I’m not saying that all heart surgery is a hoax. Far from it! Over the past thirty years, tremendous strides have been made in the surgical treatment of many once-fatal heart problems. Indeed, heart surgery is a life-saver for many, many patients.
Atherosclerosis-related conditions that do warrant surgical intervention include: disabling chest pain, despite maximal medical therapy and lifestyle changes; severe blockage of the left main coronary artery; critical blockages of all the major coronary arteries in patients with a weak heart muscle; and unstable coronary syndromes, such as an evolving heart attack.

Let me add that, at this point in time, there is a consensus that invasive procedures should be limited to the cases Ozner lists. Does this mean that no one falls into a “gray area”?  Of course not.  But in a great many cases, it is clear ahead of time—as it was for Beasley’s mother– that the risks of the procedure greatly outweigh the likely benefits.

Scandlen’s suggestion that doctors should always take the aggressive approach—even if they don’t know whether it will work—assumes that medicine is all benefit. Either it will work, or you will be back where you started. In fact, the treatment may be effective—or, it may turn out to be worse than the disease, leaving the patient dead or seriously impaired. 

As Dartmouth’s Dr. Jack Wennberg points out, a patient needs to understand that when undergoing any elective test or procedure he or she is “making a wager” that the benefits will outweigh the side effects. The physician should outline the pros and cons on each side of the equation, and give the patient some sense of the odds that he will win the gamble. The patient then needs to consider those odds—and whether she is willing to take make the wager—and place her body on the line. This is the only honest way to deal with the true uncertainties of medicine.

Finally, sometimes things just aren’t that ambiguous. An honest doctor will tell you: “we could do this—but I wouldn’t recommend it.” This is why it is always wise to seek a second opinion, and if possible, ask around for a physician who is known to practice conservative medicine. Then, a patient can make an informed choice.

7 thoughts on “Truth Squad: Fear-Mongers Ignore Risks

  1. We are a young and immature nation whose overdeveloped “can do” attitude results in overconfience in immature (sometimes unproven)technologies in medicine.
    US medicine, in addition to de-incentavizing greed needs to have a strong dose of humility.
    Also compared to other nations we have an immature fear of death.This latter issue is the issue around which the entire nation can mature
    Dr. Rick Lippin

  2. Dr. Rick–
    You wrote:
    “We are a young and immature nation whose overdeveloped ‘can do’ attitude results in overconfience in immature (sometimes unproven)technologies in medicine.
    “US medicine, in addition to de-incentavizing greed needs to have a strong dose of humility.”
    Rick– Very well-put. I agree completely.

  3. Orszag has it right and Scandlen has missed the mark. I am a practicing physician who is hostile to Obamacare. Yet, it is inarguable that we physicians are responsible for wasting of billions of dollars on unnecessary medical care. Scandlen’s comment, “It is often impossible to know ahead of time what is going to work and what won’t”, is specious. In most cases, we physicians know in advance that the tests, prescriptions and consultations we are ordering are not truly needed. Why do physicians order so much medical care? We do it to protect ourselves. We do it to appease demanding patients. We do it to make money. We do it because we are too rushed to think through the clinical issue at hand. We do it because neither we nor the patients bear the financial costs of care. We do it because medical excess is the prevailing culture of the profession.

  4. “Why do physicians order so much medical care? We do it to protect ourselves. We do it to appease demanding patients. We do it to make money. We do it because we are too rushed to think through the clinical issue at hand. We do it because neither we nor the patients bear the financial costs of care. We do it because medical excess is the prevailing culture of the profession.”
    As always, it comes down to incentives because incentives matter. We’ve discussed tort reform extensively before, especially as it relates to failure to diagnose cases when evidence based standards were followed. The litigation system is one area where, I think, we should aspire to be more like Europe.
    Patients need to better understand costs throughout the system. They need to understand how much their employers are paying for health insurance on their behalf. They should know how much procedures cost, at contract rates, before services are rendered except for care that needs to be delivered under emergency conditions. Insurers should tell them how much has cumulatively been spent on the patient’s behalf both for the current year and since the policy was first issued. I also think that Medicare should vary patient premiums by region to reflect regional differences in both per procedure costs and overall utilization of services. After all, wages for similar work vary by region. Car and homeowner insurance premiums for similar risks vary by regions as do private health insurance premiums for that matter. It doesn’t make any sense for Medicare Part B to charge the same $96.00 per month throughout the country.
    Doctors and hospitals, for their part, need some sort of accountability measurement to make them at least somewhat sensitive to the healthcare utilization that they drive. More doctors on salary plus bonus may be part of the solution, but perhaps tiering or the possibility of being eliminated from the network of approved providers should be a potential stick to mitigate excessive utilization.
    I do worry, however, that patient behavior and expectations could be harder to tame even with much better transparency around costs. If they are completely insulated from out-of-pocket costs, they probably won’t care about costs even if they know what they are. On the other hand, if they have to pay a meaningful premium or dedicated tax whether they use much healthcare services or not, they may, at the margin, feel inclined to use more services rather than less in order to “get their money’s worth.”
    At the end of the day, I think we all need to be more sensitive to the kind of world we want to leave to our children and grandchildren. Just as environmentalism has gained some traction in recent years with this motivation in mind, maybe we can appeal to the same motivation to bring about a more affordable and sustainable healthcare system.

  5. Michael & Barry
    Michael– that’s one of the best summaries of the many motives behind overtreatment that I have seen.
    We know tort reform doesn’t work to curb overtreatment. Some of hte states that have tort reform (for example, Texas) are among the high-est spending regions.
    We’re not going to raise insurance premiums for patients who happen to live in high-spending regions. Not all of them are overtreated.
    For instance, African-Americans receive less health care than the rest of the population. Why should a middle-class African American family that happens to live in LA pay higher premiums?
    That’s as logical as saying that all white people should pay higher premiums than black people beacuse, in general, white people receive more healthcare.
    As for patients having skin in the game, we know that when co-pays are higher, people are just as likely to defer necessary treatment as to skip unnecessary treatment.
    In Europe, insurance is mandates and there is no evidence that this leads to over-utilization.
    I agree that at the end of the day, we need to think collectively–about the
    kind of world we want to leave our children and grandchildren . . .
    and that it is going to
    require a great deal of re-education for patients to begin to accept the idea that more care is not better care.

  6. WHY?
    So one publication decided to lead with one opinion. As CNN loves to lead with BS from Harvard and The Commonwealth Fund.
    Why is the former “not truth?” And the latter “truth?”
    The POV in this poof-poof is 100% clear — follow the party line. At least be honest and admit it.

  7. Carlos–
    Not all truth is subjective, or based on point of view.
    It is a fact that health care reformers have no plans to slash effective care. They plan to eliminate unncessary, ineffective care–while actually raising the quality of care. .
    IF you take the time to read what Orszag has said, you will realize that he has said this many, many times.