(In reference to an anecdote about a so-called “miracle cure” for cancer, Brownlee noted that that could be the theme for her keynote talk: people hear the hope about a possible cure, but don’t hear the caveats, don’t scrutinize the evidence.)
Some of you know the story of Ignaz Semmelweis, but his story is a good reminder of the importance of evidence in medicine. Semmelweis was an obstetrician practicing in Austria in the mid-19th century; it was a time when many women died in childbirth, the result of puerperal, or childbirth, fever. [The mortality rate was between 20% and 35%.]
Semmelweis noticed that the patients who were delivered by midwives died at a lower rate than those delivered by doctors. The doctors argued: “Our patients have more complicated deliveries—that’s why they are more likely to die.” But Semmelweis observed the behavior of doctors and midwives during deliveries. He noticed that it wasn’t uncommon for doctors to go from an autopsy room directly to the delivery room, without washing their hands. He realized that they themselves were essentially passing on infections with their hands. The doctors were outraged: “Gentlemen don’t pass germs!” But Semmelweis was convinced, and he had doctors wash their hands before they saw patients and in between patients. The death rates improved. But people ignored the data, and Semmelweis was reviled during his lifetime.
The same thing happens today in broad outline. Theory often trumps evidence in medicine. People tend to believe what seems right—despite any evidence to the contrary. And it’s the lack of evidence for many procedures and treatments that drives the high cost of medicine in the United States today.
The high cost of medicine
The average family of four spends about $16,000 a year on health care. For that kind of money we should have best health care in world—and many politicians claim we do. But we don’t. In a World Health Organization (WHO) study of 39 countries, the United States ranked lower [than many other developed countries] on criteria like infant mortality and maternal mortality. We don’t have the best health care in the world—just the most expensive.
Why is our health care so expensive? Some claim that health insurance is the reason, and it does add to the overall costs because most insurance is chaotic, inconsistent, and wasteful. But even if we got rid of it, we could cut a lot of the costs—but not all. The same is true with drugs, the uninsured, immigrants.
No, the real reason for our country’s high cost of health care is that we pay our doctors more. And we pay them more because they do more: more tests, surgeries, stents, lab tests. And what’s wrong with that is that we get worse outcomes despite doing more.
The best estimates say that about 30,000 Americans die prematurely each year because of bad care. About one third of our health care dollar is spent on unnecessary care. Some estimate that the United States spends $700 billion annually in unnecessary medical care.
Regional variations on health care spending
A look at regional spending, according to Medicare figures, is illuminating. There are some minor differences in the procedures, but great variances in costs among different areas of the country.
For example, reviewing medical costs for the last two years of life for people with chronic diseases at two hospitals, we see that Medicare reimbursements per patient averaged $60,000 for those treated at Emory University Hospital, but only $30,000 at Cobb Memorial Hospital
What’s happening? How much is being done during last two years of life in terms of tests and procedures? Remember: the estimate of the annual cost of unnecessary care in this country is as much as $700 billion—that’s “billion” with a “b.”
Why is this happening? The simple answer is that doctors and hospitals are paid more to do more. Our fee-for-service system drives this. Also, malpractice worries drive doctors to give patients things they don’t need, because doctors fear being sued by patients. But malpractice fees actually account for only 15% of unnecessary care.
Doctors say that patients themselves demand more care. However, these factors are still not enough to account for regional variances.
The vast majority of unnecessary care occurs in hospitals, and it’s driven by doctors in hospitals.
Also much of the unnecessary care happens because of uncertainty in medicine. The Institute of Medicine recently estimated that only half of what doctors do is rooted in good evidence. Half of what they do is wrong and the problem is knowing which half.
Dramatic treatments, shaky foundations
The story of how bone marrow transplants became so popular for breast cancer is illuminating. In advanced cases of breast cancer, where large tumors are involved, the amount of chemotherapy needed to kill the tumor is very likely to kill the patient as well. Bill Peters was a doctor who tried a different approach when he treated a woman with a melon-sized tumor: giving high-dose chemotherapy followed by a bone marrow transplant to reconstitute the woman’s immune system. The cancer went way (although the patient died). He tried this technique on three additional women, and the survival rate improved. This was extraordinary, so his findings were rushed into press. Within first year, media coverage began. Slowly, the story started coming out.
Bill Peters did an historical control study—that is, he compared case studies of patients who were treated with standard chemotherapy with his patients who received chemotherapy plus the bone marrow transplant. That was a reasonable study to do, but not proof that the bone marrow transplant made the difference. Nonetheless, the story ripped through oncology world. The press started writing about it in Homeric terms. The procedure was very expensive and the profits were big, too: $50,000 per transplant. So, all hospitals wanted bone marrow transplant teams. But the treatment still didn’t cure patients.
18 years later, results from four of five clinical trials found that the experimental treatment with high-dose chemotherapy showed no clear advantage over conventional treatment. As I note in my book Overtreated:
“Peters’s trial, the largest by far, with data from nearly eight hundred patients, showed that the women who received a transplant were slightly more likely to be cancer free after five years than women who received conventional therapy—but the advantage was wiped out by the fact that they were also more likely to die from the treatment.”
The impact of unnecessary care on real people
We see similar problems with other technologies. For example, I heard an anecdote about a patient in a small town in the South. The elderly patient came from a nursing home to the hospital. He was demented and also had many serious health problems, and had undergone coronary bypass surgery and had a defibrillator inserted to regulate his heartbeat.
While he was in the hospital, the defibrillator went off. He panicked and started crying: “Stop doing this to me!” He didn’t realize that it was a device in his own chest. He just knew that he was in great pain. Sometimes, the families insist on doing everything for an old and sick patient.
So your reporting has real meaning for real people as well as for the nation’s economy.
The Congressional Budget Office predicts that health care will account for 50% of our gross domestic product (GPD) in the next 50 years. Obviously, that’s not sustainable. My hope is that as we journalists write about medicine, we look at it with great skepticism.
More is not necessarily better.
Question and answer period
Q. What is a good source for information about regional variations in health care?
A. The best resource is Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008. It describes how care for Medicare beneficiaries with serious chronic illness varies across U.S., states, regions, and hospitals. The focus is on Medicare beneficiaries who have severe chronic illnesses and are in their last two years of life. For more information, see the website: www.dartmouthatlas.org
The problem is that hospital costs and charges are not transparent to the consumers. However, there’s good journalism in this area, including the journal BMJ, and the economic sections of the Wall Street Journal and The New York Times.
Some of problematic writing that relates to health care costs appears in health section of various publications. Sometimes, journalists don’t want to pick up things that fly in the face of “truth”—for example screening tests like PSA and mammography or widely accepted drugs like statins (common cholesterol-lowering medicines). All these things should be written about in a critical way. Don’t just accept journal articles—even good ones like the New England Journal of Medicine—without asking hard questions.
Comment from Pat Thomas: In your own reader or listening area, look at variances in hospital costs, physicians’ pay, drug costs, and so on. Try to understand what medical problems are most likely to cause patients in your area to be hospitalized. Use the Dartmouth Atlas to help understand what’s going on. You can tell the readers and listeners that things might cost more in the last two years of life because of more doctors, more tests, more procedures.
Q. Are there variances in costs, internationally?
A. Yes, and it’s important to look beyond American borders and appreciate the benefits of other countries’ health care and to make cross-cultural comparisons.
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