Tuesday, March 4th, 2014.
Topic: Medical Over-diagnosis and Over-utilization, Ethical Factors.
Presenters: Rose Marie McMahon, RN and four retired MDs: Jim Field, Dick Konys, Gerry Schroeter and Isam Sakati.
Moderators: Neil Funnell John Miller
Jim Field, MD, graduated from Harvard Med., did his Residency in Internal Med at Mass. General Hospital, worked at NIH Public Health Service, He taught at University of Pittsburgh and Baylor Med Centers. Jim is currently working as the endocrinologist at our VIM Clinic on HHI.
Richard Konys, MD, FACS , practiced Vascular Surgery in Syracuse, NY, where he served for many years. as Professor of Surgery at NY State Medical University, Upstate.
Rose Marie McMahon, RN, received Her BS Nursing at Boston College, MS at Adelphi and served as Professor of Nursing at City University of NY, Regents College (now Excelsior University of NY). She presently works as a Volunteer Nurse at VIM.
Gerald Schroeter, MD, FAAN, graduated from St. Johns University, of Ottawa Med School, Residency in Neurology at Bronx VA Hospital in NYC. Gerry practiced Neurology in Huntington/Glen Cove NY for 32 years and currently at VIM Clinic.
Isam Sakati, MD, is a Board certified Urologist, practicing as a Urologist for many years in Utica NY, before retiring to HHI. He also lectures and gives courses at our Lifelong Learning Center on HHI.
Books utilized for reference: “Over-diagnosed” Making People sick in the Pursuit of Health, by Dr. H. Gary Welch from Dartmouth; “How We Do Harm”, by Dr. Otis Brawley of American Cancer Society.
Gerry started the discussion by defining “over-diagnosis” (according to Brawley & Welch), as “the diagnosis of a cancer that would otherwise not go on to cause symptoms or death.” Americans spend roughly $2.8T/yr. on healthcare (~18%of our GDP). He commented on the extent of over-utilization: The Congressional Budget Office reported that up to 30% of our annual health care costs are unnecessary. (~ 1/3 of our ordered tests). Add on other cost factors: financial, emotional, physical, for the patient and public. There are also many health conditions which are defined by numbers, or benchmarks—like high blood pressure, high cholesterol, diabetes, and osteoporosis—numbers that distinguish between who’s healthy and who’s sick. these numbers are always changing in one direction: the direction of labeling more and more people as abnormal. The problem is that these newly created patients stand to benefit the least from intervention, and the net effect of intervention may be harm. Who benefits from “over-diagnosis”? : Insurance companies, Lobbyists, Big Pharma, device manufacturers, imaging centers, certain specialists & their self owned/operated “detection” devices, and your local hospital, to name a few. A personal friend’s wife just went through an expensive, somewhat painful procedure, that they both thought was a bunch of “hoo-wee", and of course it turns out to be nothing significant, thankfully, but when you have the resources (Medicare or private insurance) “why take the chance”– which the medical profession wants to foster”. He asks “how much of our personal/ national resources should be spent on prolonging the ultimate outcome”.
Our MD/DO Hippocratic Oath preaches “Do No Harm”!!! We are turning this into a hypocritic oath. It is high time that we, in our once hallowed Medical Profession, healed ourselves, so that we can help to appropriately guide our patients to heal themselves and lead healthy, productive lives.
Rose Marie added that National Health spending is expected to grow Faster than the economy. By 2037, it is expected to increase from 18% to 25% of the GDP and from 25% to 40% of federal spending. These increases would reduce funding for education, infrastructure, paying down the National debt. along with cuts in numerous other areas. We need reform from sick care to healthcare. Robert Wood Foundation, states that Billions of dollars in health care spending could be saved yearly by avoiding unnecessary tests, treatments, ER visits hospitalization and a reduction of complications.
The Institute for Healthcare Improvements, formulated a business model known as the “Triple Aim”. This model is a three pronged approach to reform: Population Health,
Quality Care, and Reduction in costs per capita. This model would oversee how health care is provided and paid for, and track care outcomes. The Center for Medicaid & Medicare Services, is presently using this model in Accountable Care Organizations (ACOs), physician network groups and medical homes. Recently we have seen many
Dick remarked on “The changing Medical practice environment and its effect on over ordering of diagnostic studies and over performing medical procedures and their ultimate contribution to increased health-care costs.” He listed three components to this problem: Hospitals, Physicians, Patients. There are many complex causes and many cultural factors for over-utilization, based on these above 3 components. Other reasons for over- utilization include: Financial incentives for self-referrals; Malpractice and defensive medicine; Consumer advertising leading to increased patient demand for services; Professional and cultural biases.
He concluded with the results of Over-utilization: Increased patient anxiety, discomfort; False positive readings and ”Incidentalomas”; Over exposure to radiation and chemicals; Procedural complications; Overloading of diagnostic services.
Isam commented on PSAs and prostate CA over-testing and associated problems from his many years of practice and experience in Urology. PSAs: The American Cancer Society and the American Urological Association (AUA), recommend that men 55 to 79 discuss the pros and cons with their physicians and then make an informed decision. Those men that are at high risk should have screening. Routine screening is not recommended for average-risk men 40- 54, after age 70, or for men with an average life expectancy of less than 10 to 15 years. The AUA has recommended against screening PSA tests for men younger than 40. The frequency of future testing will depend upon their prior levels and symptoms. Routine PSAs are no longer recommended for patients over the age of 75.
Jim concluded our panel discussion by noting the varied ways to reduce over- utilization. He made reference to The Choosing Wisely Initiative. and noted that there were some 40 specialty groups who made recommendations on how to improve health care, even though this was against their own personal financial interests. The Annals of Internal Medicine, 2012, noted 37 common clinical situations, where clinical & diagnostic tests were of little benefit.
Jim finished with some final recommendations:
Questions we all should ask of our physicians—Caregivers:
Do I really need these tests or procedures?What are the potential risks and how will this affect my treatment?
Is there a safer and perhaps simpler procedure? What happens if I do nothing?
What are the costs?
How much is spent on so called defensive medicine?
Answer: Estimates range from $50-400 Billion from varied study reports.
The System in England seems to work well for all residents and covers all people.
We should have a Single Payer system in the US.
A single payer system is not the answer. People from Canada often come to the US for their MRIs or joint replacements.
An attorney in our audience remarked that the medical malpractice problem should be appropriately addressed and amended.
A retired insurance company representative stated that insurance companies have a very low profit margin in his experience. He also felt that people with high risk problems or those who do not take proper care of themselves, should have to pay a higher premium, to be fair to all.