Overdiagnosed and Overtreated: Where’s Mine?

I recently read that mild high blood pressure is turning out to be one of the most overdiagnosed and overtreated health conditions. Untold millions are taking meds they probably don’t need, possibly experiencing unpleasant side effects in the process. The actual history–why we’re all taking inordinate amounts of blood pressure meds–was revealed when it was disclosed that the standards for “normal” blood pressure were set in the 1950s at a huge European medical meeting, underwritten by a pharmaceutical company introducing its latest blood pressure medication.

But the problem of overdiagnosis and overtreatment is certainly not limited to blood pressure. Epidemiological studies conducted throughout the US agree on this. As a nation, Americans are labeled with diagnoses for conditions that may not be particularly dangerous and as a result are encouraged toward medicines and operations that can be risky and may not improve quality of life at all.

Large reviews analyzing conditions as diverse as medical treatment for depression, high cholesterol/blood pressure, surgical intervention for heart disease, uterine fibroids, arthritis, breast lumps–even thyroid and prostate cancers–all end with two basic conclusions: “too many” and “mainly unnecessary.”

The medical term for this excess is overutilization.

Income and insurance drive overutilization

Overutilization (which you can also think of as overtreatment) is at the heart of why the US healthcare system is so egregiously expensive, consuming at last calculation about 17% of our GNP annually, roughly $3.8 trillion—that’s a “T”–or pretty much at least twice that of other developed nations. Not surprisingly, overutilization occurs most predominantly in areas of the country where patients have the highest per capita incomes and the most complete insurance coverage.

Depending on who you interview on the subject, disparate reasons are given for overutilization:

• If you ask doctors, protected by titanium-strong egos, they’ll place the blame squarely on patients and malpractice lawyers. They say patients ask for more tests than ever, demand that every symptom be immediately diagnosed and treated, and want a quick fix, medication first (the one they just saw on TV) and surgery second. If the physician is unable to provide the desired tests/treatments, the patient will simply go elsewhere and have all her tests repeated.

Doctors also see themselves practicing under a cloud of impending malpractice suits. They’ll test for everything so as not to be blamed for lack of thoroughness. Does the young woman with irritable bowel syndrome really need a third colonoscopy? Does every man who snores really need that sleep study and a CPAP machine?

• Patients, not surprisingly, blame overutilization on the health care system. Surgeons are one-percenters who do surgical procedures, so if they have to choose between performing or not performing surgery, the patient usually finds herself in an operating room. An extraordinary number of cardiac stents, joint replacements, and prostate/thyroid/breast lump removals have turned out to be useless at improving either quality of life or longevity. (An orthopedic surgeon I know recently joked that the two indications for back surgery were: 1. Does the patient have insurance? and 2. Does the patient have a back? Not funny, I know.)

Money money money money—money!

Take a look at this chart to appreciate how we in the US do more of everything compared to other countries in the Organization for Economic Co-operation and Development (OECD), an international economic group. There’s more information at this link.

The term Occam’s Razor refers to a problem-solving principle devised by 14^th century philosopher William of Occam. It states that among competing explanations for any problem, the answer with the fewest assumptions should be selected. Other explanations may be correct, but the one with the fewest possibilities is the best.

Often shortened to “the simplest explanation is the best,” if we apply Occam’s Razor to overdiagnosis and overtreatment, the answer with the fewest alternative possibilities is money.

I’ll bet you saw that coming.

Doctors make more money doing operations, necessary or not. Hospitals and their egregiously paid executives make more money when their beds are filled with patients having operations. For example, hospitals do nicely with back surgery. Alternatively, each time a chiropractic physician successful treats a patient with a disc problem, and the patient avoids hospitalization, that’s $100,000 down the tubes.

Pharmaceutical companies make money if you swallow their pills rather than (heaven forfend) living a healthful life. Your local pharmacy makes more money filling your prescriptions than it does selling you cigarettes (although it would prefer to do both… “Happy and Healthy,” remember?). Even such benign and dedicated health care providers as physical therapists, occupational therapists, and psychotherapists all want you to keep coming back for more.

Overutilization permeates everything

Here are some of the latest findings on overutilization and overspending (brace yourself, these are seriously irritating):

1. EMRs The theory behind the now-required electronic medical records (EMRs) was to enable easy sharing of health data among providers and avoid unnecessary duplication of services. But the system was wrong from the get-go. With more than 500 competing EMR companies, nothing gets shared because no two systems can communicate with each other. Instead, EMRs are essentially used by health insurance companies to determine reimbursement rates to physicians, which appears to mean if your doctor puts more data on your records he’ll receive more money from your insurance company. All EMR systems have automatic templates–big chunks of prewritten information that can be added to your record with a click. Using these templates indiscriminately can add pages of (useless) data to thicken your record and fool the insurance company into thinking you’re receiving all sorts of services you’re really not receiving at all.

In pre-EMR days, a typical consultation from a specialist would be a page or two long, with the most salient notes and recommendations at the end. Handwriting interpretation occasionally required a Rosetta Stone, but we primary docs got used to it. Now the consultations run to about ten pages of electronic junk, even though the specialist herself hasn’t spent a minute longer with you. Since it takes some medical experience to differentiate junk EMR diagnoses from legitimate ones, you could be labelled with (and treated for) a condition you never had in the first place because a physician clicked an inappropriate button on the EMR template.

Example: Nausea from a prescription drug triggers a referral to a gastroenterologist for a gastroscopy instead of simply discontinuing the drug.

2. The drive-by doc, a new phenomenon in overutilization. In the past, if your surgical procedure needed a second pair of hands, the surgeon would bring in a surgical resident. Most often, your surgeon is in your insurance network. This means his fee is predetermined, and insufficient for his Lamborghini payment. So now, instead of a surgical resident, he deliberately brings in a non-network surgeon, who can charge whatever he likes and you are obligated to pay. (Read this NYT piece to fully grasp the implications.)

Since the fee can be tens of thousands of dollars of course you can’t pay it, but your insurer will cover it under your out-of-network benefit, so you’ll “only” be responsible for 30%. Delighted to be receiving the 70% add-on, your network surgeon and his out-of-network assistant split this largesse and probably won’t bother you for the balance. Your surgeon gets to keep his Lamborghini and if your bill is still overwhelming the financial services department of the hospital will refer you to someone to assist with the refinancing of your condo.

3. If you’re a user of certain generic medications, you may recently have collapsed in front of your pharmacist when she informed you of new price increases, occasionally as high as 1,000 to 2,000% (this is no typo). The latest new venture among health care vultures is to purchase a small pharmaceutical company making an old generic drug, buy back the distribution rights from other companies, be the only guy in town selling the drug, and charge whatever they like. I’ve previously written about how an injectable med called ACTH went from $9 for a 5-ml vial to $19,000 for the same vial. A small tube of cream for athlete’s foot rocketed from $8 to $120.

This latest rape of the system is being investigated by the Feds, but remembering how well they did with their pre-meltdown investigation of Goldman Sachs, don’t hold your breath.

What all this means is we’ve become too dependent on a health care system that does not have our well-being as its top priority. It brings to mind the late newspaper columnist Mike Royko, who felt Chicago’s motto should be changed from “I Will” to “Where’s Mine?”

And what this really means, as if you don’t know by now, is take care of yourself.

Be well,
David Edelberg, MD