Saturday, May 16, 2015

Atul Gawande feature on unnecessary medical care

There's a really fascinating piece of writing by Atul Gawande (who I've posted about a few times previously) from a recent New Yorker with "Overkill" on unnecessary, expensive and often harmful medical care provided. In terms of the scope of the problem, Gawande writes below...

"In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services."

The reasons for the waste, or no-value care as Gawande describes it, include tests and treatments both unethical recommended (with providers trying to collect all available insurance and Medicare dollars) and simply not needed, often as a result of there being so many tests and treatment paths available. What occurs is doctors, with patients buy-in, often test for problems that really aren't likely to have a terrible result if the problem found in someone, and then treat the problem because it's been discovered. The issue from this is the care costs money for someone, whether an individual paying out of pocket, an insurer (who as a result may raise rates) or government. Additionally, testing can bring complications for patients, not to mention problems that can result during procedures; and treatment for a given ailment can preclude different, and perhaps more needed, treatment for the same or another ailment.

Just as interesting to me as the problems that Gawande presents is the better path that he provides in the piece, with two examples including one driven from a corporate perspective and one out of a government act. Gawande tells the story of a Walmart employee with back problems who had surgery recommended to him and could have had the procedure done locally, with large out-of-pocket expense incurred, or follow a path Gawande wrote about...

"Taylor had heard about a program that Walmart had launched for employees undergoing spine, heart, or transplant procedures. Employees would have no out-of-pocket costs at all if they got the procedure at one of six chosen “centers of excellence”: the Cleveland Clinic; the Mayo Clinic; Virginia Mason Medical Center, in Washington; Scott and White Memorial Hospital, in Texas; Geisinger Medical Center, in Pennsylvania; and Mercy Hospital Springfield, in Missouri. 

Walmart wasn’t providing this benefit out of the goodness of its corporate heart, of course. It was hoping that employees would get better surgical results, sure, but also that the company would save money. Spine, heart, and transplant procedures are among the most expensive in medicine, running from tens of thousands to hundreds of thousands of dollars. Nationwide, we spend more money on spinal fusions, for instance, than on any other operation—thirteen billion dollars in 2011. And if there are complications the costs of the procedure go up further. The medical and disability costs can be enormous, especially if an employee is left permanently unable to return to work. These six centers had notably low complication rates and provided Walmart a fixed, package price."

Gawande writes of how Taylor went to Virginia Mason in Seattle, and after examination there, was recommended to not have back surgery, and instead focus on recovery through rehabilitation, an approach that Taylor agreed to and as Gawande quotes him saying, "within a couple of weeks, I was literally pain free." It's a fascinating story and not entirely unexpected one as Gawande writes of the Walmart program around spine, heart or transplant procedures...

"Two years into the program, an unexpected pattern is emerging: the biggest savings and improvements in care are coming from avoiding procedures that shouldn't be done in the first place. Before the participating hospitals operate, their doctors conduct their own evaluation. And, according to Sally Welborn, the senior vice-president for benefits at Walmart, those doctors are finding that around thirty per cent of the spinal procedures that employees were told they needed are inappropriate. Dr. Charles Nussbaum, until recently the head of neurosurgery at Virginia Mason Medical Center, confirmed that large numbers of the patients sent to his hospital for spine surgery do not meet its criteria."

As a wrap-up to Taylor's story, Gawande provides the following...

"If an insurer had simply decreed Taylor’s back surgery to be unnecessary, and denied coverage, the Taylors would have been outraged. But the worst part is that he would not have got better. It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative. Walmart, of all places, is showing one way to take action against no-value care—rewarding the doctors and systems that do a better job and the patients who seek them out."

Another thing Gawande writes of as leading to optimism for care in the future is out of a provision in the Affordable Care that "allows any group of physicians with five thousand or more Medicare patients to contract directly with the government as an 'accountable-care organization,' and to receive up to sixty per cent of any savings they produce." Gawande writes fairly extensively of McAllen, TX and how "two McAllen accountable-care organizations together managed to save Medicare a total of twenty-six million dollars. About sixty per cent of that went back to the groups. It wasn’t all profit—achieving the results had meant installing expensive data-tracking systems and hiring extra staff."

It's a fascinating piece from Gawande and as he towards the end writes "waste is not just consuming a third of health-care spending; it’s costing people’s lives."