ABC Nightline Interview aired Tuesday, Aug 11

As regular readers know, Academy-Award-winning documentary film-maker Alex Gibney (“Enron: the Smartest Guys in the Room,”  “Taxi to the Dark Side”) has produced a 90-minute documentary based on my book, Money-Driven Medicine. Andrew Fredericks directed the film and I narrated it. 

ABC’s Nightline interviewed Alex and me about the film in a segment that aired August 11. Below, a link. (When you get to the website, scroll down and click on Nightline, August 11 on the left hand side of the screen)

Money-Driven Medicine producer Alex Gibney and author Maggie Mahar interviewed on Nightline's Tuesday, Aug 11 show.

Watch the interview here.

If you are interested in either buying or renting a DVD of the film, go to www.moneydrivenmedicine.org.

Comments

[Legacy Flyer]

Lisa,

I admit to frequently playing the role of critic rather than cheerleader, but have offered a number of (what I think are) useful suggestions.

Rhetorical question – who do you think does you the greater favor – a friend who tells you that you look great - even if you don’t, or a friend that points out that your shoes are untied or your zipper is not zipped? Similarly, should the comments at the end of each posting consist primarily of affirmations (“Great post Maggie!”) or should they include criticism, objections and alternative views?

With respect to the specific issue: “Is mammography over used”, I actually agree with Maggie that it is. (I have been reading mammograms, doing needle localizations and breast biopsies for over 20 years.) But the reality is that physicians are not free to practice medicine as they see fit (nor does Maggie want them to) but must respond to legal and social pressures. The idea that physicians could stop recommending mammography based on the recommendations of a single organization when the preponderance or major organizations recommends otherwise is foolish. And physician’s behavior is heavily influenced by the threat of malpractice – but not always in the way Maggie and you might wish.

[Maggie Mahar]

Lisa, Legacy, Ed

Lisa-- I understand your frustration.

Legacy-- Very likely a lay jury might well convict a doctor for not recommendig mammograms. Though given the fact that so many people do still believe in routine , an intelligent defense lawyer might well make the argumetn that the woman had every reason to know that this was teh convetional wisdom (whether or not her doctor urged her to go for mammograms,) and that she chose to ignore the advice.

In Tobacco cases, if the smoker began smoking in the 1980s, lawyers often win by making the argument that the smoker should have known that cigarettes are hazardous to your health --and the tobacco company wins.

If the smoker began in the late 50s, when the dangers were not so well known, he is more likely to win his suit against company.

More importantly we need to find a different way to deal with malpractice suits (as I have written in earlier posts.)

Ed--

I think you're right that, to some degree, all systems eventually get gamed--or at least begin to show cracks. (It would be pretty difficult to "game" the system in Sweden--they have kept spending flat even as the population as aged. There just aren't many/any opportunities to make huge profits.)
So healthcare reform is always going to be an ongoing process . . .

[Lisa Lindell]

Legacy Flyer,
Will you ever be offering any actual useful suggestions =, or is it your sole purpose to come on this blog just to forcefully prove how right you are and how everybody and anybody else's useful suggestions would never work? It seems all you ever do is attempt to tear down what others are trying to build.

[Legacy Flyer]

P.S.

Important point not spelled out in the above hypothetical case. Her OB/GYN has not been recommending year mammography.

[Legacy Flyer]

Maggie,

Here are the CURRENT RECOMMENDATIONS about screening mammography from various organizations:

American College of Obstetrics and Gynecology (ACOG) (probably the most influential since OB/GYNS order the most mammograms)
• 40 to 49, every other year
• 50 and older, every year

American Cancer Society
• 40 and older, every year

U.S. Department of Health and Human Services (HHS)
• 40 and older, every year

American Medical Association (AMA)
• 40 and older, every year

American College of Radiology (ACR)
• 40 and older, every year

American College of Physicians (ACP)
• 40 to 49, individual decision based on risk factors
• 50 and older, every year

I also suggest that you present the following set of facts to a plaintiffs attorney that you know:

A 55 year old woman, who has been under the care of her OB/GYN for the last 15 years and who has no significant risk factors for breast cancer develops a Stage 2 breast cancer - discovered by her while taking a shower.

She consults an attorney and files a malpractice case against her OB/GYN. The attorney obtains 3 expert witnesses who say:

a) OB/GYN - He follows the recommendations of the ACOG, AMA, American Cancer Society, etc. and recommends yearly screening mammography. He believes that not doing so is a “violation of the standard of care”
b) Oncologist – He says that had her cancer been discovered at an earlier stage she would have a better prognosis
c) Radiologist/Mammographer – She says that, “to a reasonable degree of medical probability”, had the woman had regular mammography the tumor would have been picked up at an earlier stage. Furthermore she says that the “preponderance of the medical evidence” supports yearly screening after age 40

If the attorney you consult doesn’t believe that this is a good case I will “eat my hat”. (I have 20 years of experience reviewing malpractice cases including a number of breast cancer/mammography cases)

You say that I am “behind the times” and suggest that I read the post by Naomi Freundlich – which I have. I agree with you that the benefits of screening mammography are over-rated, however the preponderance of current medical opinion, as manifested in the recommendations of the major societies is against us. If you believe that the recommendations of the The National Breast Cancer Coalition Fund bear more weight than all of the above organizations, you need a reality check!

[Maggie Mahar]

Legacy,

Legacy--Did you read the post where a hospitalist tells his residents the truth?

He is teachign them to order fewer MRIs etc.

On Mammograms, you're behind the times. See this statement from The National Breast Cancer Coalition Fund : "The scientific evidence from randomized trials on the impact of screening mammography in saving lives is conflicted, and the quality of the individual trials limited. The National Breast Cancer Coalition Fund (NBCCF) believes, on the basis of recently published reviews, that the benefits of screening mammography in reducing mortality are modest and there are harms associated with screening."
For the full statement see Naomi Freundlich's post here: http://www.healthbeatblog.com/2009/04/mammography-screening-a-double-edged-sword.html.
She also quotes the American College of Physicians, which also raises questions routine mammographies.

Many younger physicians are becoming more proactive about avoiding unncessary tests. The work
that has been done up at Dartmouth about the "epidemic of diagnosis" has gotten a great deal of attention, in the mainstream press as well as in medical journals.

Evan--

Thanks for your comment.

I agree that the whole idea of being "thorough" is embedded in the culture.

Traditionally, residients have been praised for ordering every test possible.

That needs to change--which is to say we need to change how we train medical students.

We also need to pay primary care docs more--and forgive their loans (the House bill does both) so that they can spend more time with patients diagnose the problem and recommend treatment --rather than simply referring the patient to a specialist.

That said, I would add that in settings where doctors are on salary, we do see less over-treatment.

Medicare spends up to 50% less when patients are treated in a multi-specialty center where all doctors are on salary than it spends when a very similar patient is treated in a setting where doctors are paid fee-for-service . . And outcomes are generally better in the centers where Medicare pays less.

[Evan Ballard, MD, Family Physician]

Maggie,
You and others (the oft quoted article in the New Yorker about McAllenville, TX)stress the importance of the profit incentive in doctor's excessive test and treatment ordering. While I'm sure that incentive is important, I think that it is not the main driver of our overutilization. In my 30 years of family practice I observe doctors, especially primary care doctors, overutilize tests, brand name medications, and referrals while receiving no financial benefit at all. I think the overutilization is deeply embedded in the culture of medicine.
Our medical training stresses completeness. We are taught to be sure we consider all possible diagnoses, no matter how unlikely and no matter what the cost and with little understanding of the possible harm to the patient of misleading results of the tests we order.
Primary care doctors seem less and less willing to take responsibility for managing complex problems that they are well trained to do. Unnecessary referrals add to our costs tremendously and fragment the care of our patients such that there cannot be adequate coordination of their care.
I don't know how to address this in the revamping of our system. However, if we don't figure that out we will miss a big opportunity to lower cost and to improve quality.

[Legacy Flyer]

Maggie,

You say:

"See Dr. George Lundberg's recent post on The Health Care Blog"

I read it and agree that it is a good post. It omits a number of other things that could save substantial amounts of money - such as reforms in how drugs are priced and ordered.

As for whether this is something that patients and docs can actually "do", I am afraid that you are very naive about that.

His #5 (overuse of CT and MRI) directly relates to my specialty. As you know, I have previously expressed the opinion that there is a significant amount of overuse of CT and MRI.

In the old days, Radiologists used to have to approve CTs done after hours. I soon learned that this was a dangerous and thankless job and the best thing to do is approve everything that you can't talk the referring doc out of ordering. Clinicians don't want you standing in the way of their ordering the studies they want and neither do the patients. Turn down a study at night that later turns out to be positive during the day and you are screwed.

As for his #4 - forget about it - it is pretty clear that he hasn't practiced medicine in quite a while. The most influential organization with respect to Mammography is the ACOG - here are their guidelines:

- Age 40-49, every other year
- Age 50 and up, every year

If you practice OB/GYN (the docs who order the most mammos) and don't follow the guidelines and one of your patients develops breast CA (and sooner or later one will) you are similarly screwed.

(Did you read how many comments Lundberg got from people disagreeing about his mammo recommendations?)

There will be little change in the over ordering of tests until there are guidelines that offer protection for following the guidelines - (or everyone is in HMOs where docs lose bonus money for each test they order)

Time for a little reality check for you and Lundberg.

[Maggie Mahar]

Legacy Flyer--

See Dr. George Lundberg's recent post on The Heatlh Care Blog (www.thehealthcareblog.com )
It's a brilliant delclaration of what docs and patients can do. I plant to write about it here--and commented on it there.

[Legacy Flyer]

From end of the clip:

"We should take health care and put it back in the hands of the patients and doctors"

What a wonderful slogan. - What does it mean - who knows.
- How do we achieve it - with a 1,000 page piece of federal legislation?

Can I get that guy to be my speechwriter?

[Ed]

I think what the french have found is that all systems eventually get gamed. Part of the issue I think is to accept that whatever the solution is now, it will have to be overhauled later. Perhaps the real solution is planning for change.

Private -> Mixed -> Public -> Mixed -> Private.

Accept that this is a situation where a pendulum must swing, perhaps every decade, to keep the gamers from taking too much.

[NG]

Maggie,

My point is that if the French government is the only payer (and I do not know if they are btw), it becomes a monopsony payer to the hospitals or providers or whatever! That means the government can dictate prices and whether it pays at all. Rather than pay a capitated rate or something like that, maybe the government can get more info about what it is paying for by paying a controlled FFS. It always has the last say on amounts if it is a monopsony payer.

Definition of Monopsony from Wickepedia:
In economics, a monopsony (from Ancient Greek μόνος (monos) "single" + ὀψωνία (opsōnia) "purchase") is a market form in which only one buyer faces many sellers. It is an example of imperfect competition, similar to a monopoly, in which only one seller faces many buyers. As the only purchaser of a good or service, the "monopsonist" may dictate terms to its suppliers in the same manner that a monopolist controls the market for its buyers.

[Maggie Mahar]

NG-

Pat S. points out that French doctors are on salary. So even if the hospital is paid fee-for-service, doctors will have no unconscious incentive to "do more"-- their pay won't be affected.

And doctors (not hospitals) are the ones who decide to order tests, procedures, etc.

[NG]

c8tt"What do the French know (or think they know) that we don’t?"
--------
Maybe that a monopsony payer can dictate the price paid or if anything will be paid?

[Pat S]

Everyone has issues with health costs. Everyone has issues with health quality. It's just that the US has more issues on those things than anyone else, since cost is much greater and quality worse.

Fee for service components exist in most countries. However, it is interesting to note that the fee for service for French hospitals is for the institution, not the doctors. The doctors in almost all French hospitals, private and public, are employees. In that respect France resembles the Mayo Clinic, which is a fee for service health care system that pays its employees, including all its doctors, on salary.

[Maggie Mahar]

Heather--

Thanks much for your interest.

If you go to http://www.moneydrivenmedicine.org/ and scroll down, and look on the left-hand side of the page, you will find,that you can buy or rent the DVD-- starting Aug. 20

[heather Whinna]

I cannot find screening info for this doc. How do I see this film? Thanks!

[Legacy Flyer]

Slightly off topic but …

Interesting article in the Wall St. Journal on Friday August 7th titled: “France Fights Universal Care’s High Cost”.

France has a high quality universal health care system that costs approximately half (as a percent of GDP) of what the US health care system costs. However, the rate of inflation of health care costs in France is causing problems for the French government which is trying to introduce various cost saving measures.

Interestingly, “France is actually in the midst of shifting to a fee for service system for its state run hospitals. The hope is that it will be easier for the government to track if the money is being spent efficiently …” What do the French know (or think they know) that we don’t?