Word is that Sen. President Therese Murray’s cost control legislative proposal is coming soon — maybe this week or next. As we kick off what we hope will be a vigorous cost control discussion, it may be helpful to start with a joint reading project. I have a book suggestion — Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer – by Shannon Brownlee of the New America Foundation.
Health policy specialists identify three categories of poor quality — underuse of necessary care, misuse of care, and overuse of unnecessary care. Overtreated is an entire volume devoted to understanding the third category. A lot of it is familiar terrain — prescription drugs, imaging, bone marrow transplants for breast cancer. Yet it’s powerful to read all these examples of overuse assembled in one volume.
Many prominent health thought leaders, such as Dr. Don Berwick at the Institute for Healthcare Improvement, have asserted for years that as much as one third of health spending is clinical waste. Overtreated is a great compendium to back up this assertion. And it’s an appropriate place to start the health cost control conversation.
John McDonough
Good point, Petr. And maybe the answer is that there may be a difference in emphasis that is needed in each setting. For example, at BIDMC, we have committed ourselves to eliminating preventable harm over the next four years (by the way, with public reporting of our progress.) That is the strong focus of our managerial and clinical programs in that this mission is what motivates our doctors, nurses, and other caregivers.
This might be a different emphasis say, from an insurance company, which has more of an interest in reducing overuse and waste. Such an organization might invent ways, through rembursement redesign, to encourage providers to focus on that aspect of the problem. Providers will respond to those price signals, but they will not be highly motivated (in a mission-driven) sense by them.
There is a difference, it seems to me, between waste (that is, no effect) and hazard (that is, ill effect). “Overtreated” looks to address the hazard issue, not the waste. So the statement “Overtreated is a great compendium” isn’t strictly true, wrt to the hazard of health care. This only serves to obfuscate the issue. (e.g., “Gee, that money I spent on rat poison is wasted since it killed the dog instead…” doesn’t help.)
An essentially conservative approach like “do no harm” ought to accept,perhaps even welcome, a certain amount of effort without effect (waste) while maintaining constant vigilance against ill effect as the cost of best coverage. Baseball players, stock brokers and the local weatherman all waste the larger share of their efforts. Why should we expect the health care industry to be any better?
Creating a bogeyman out of waste, when harm is the real danger, not only obscures the real issue, but actually prevents adequate response.
“Which one third?”… Why the one-third that hurts
Of course, this raises the question: “Which one-third?” If I am a typical consumer, if it is the test or treatment that I demand and expect for myself, my spouse, my child, or my parent, then I won’t consider it a waste! There, I suggest, is a lot of the underlying problem. There are things we as consumers expect and demand here in the US that are not part of the usual course of health care in other countries.
Of course, there is also supply-driven overuse that deserves lots of attention.
You might add Don Berwick’s book, Escape Fire, to your reading list as well.