16% of all spending in the US is on healthcare. About half of that is spent by federal, state, and local governments, and the other half is spent by the private sector. In 1970 about 7% of all spending was for healthcare. Total annual spending on healthcare per person has increased from less than $1,000 in 1970 to about $8,000 now.
Defenders of our current healthcare spending are quick to point out that while we’re spending much more, we’re getting much better healthcare. New technological developments are constantly bringing better treatments to patients, and patients are living longer. The increased expense, they would argue, is worth it. But we shouldn't believe them. In all other sectors (housing, transportation, food, …) quality improves while prices drop. We spend a smaller fraction of our money on transportation than we did a generation ago despite the fact that cars are safer and more fuel efficient and that commercial airline travel is inexpensive enough to be enjoyed by the middle class. We are right to expect medical care to become both better and cheaper over time.
Why hasn't it? I believe our current insurance payment system rewards overutilization and drives prices up. (I wrote a series of posts analyzing the issue in 2009.) Because the vast majority of healthcare dollars are not paid by the patients receiving the care, there is little disincentive to provide care that has little or no benefit. In fact there is a great incentive to the doctor to provide as much such care as possible.
Besides high prices, this has resulted in a healthcare culture in which doctors offer and patients have come to expect tests and treatments which have been proven to be entirely without benefit. Last April in an attempt to educate both doctors and patients about interventions that are valueless, the American Board of Internal Medicine Foundation partnered with a number of physician specialty societies and formed an initiative called Choosing Wisely. I wrote about it at the time. The program listed 45 different tests and treatments in nine different specialties that doctors shouldn't offer and that patients should question.
This week, Choosing Wisely has expanded this list. Many new physician specialty societies have come on board and the list of valueless tests and treatments has grown to 90. Among the new recommendations are:
- Don’t perform EEGs for headaches. The American Academy of Neurology finds that EEGs don't help in diagnosing the cause and do not improve outcomes.
- Don’t recommend feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. The American Geriatrics Society reviewed the evidence that careful hand-feeding is as safe in patients with severe dementia and that tube feeding leads more frequently to agitation and worsening skin sores.
- Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. The American Geriatrics society reminds us of the risks of motor vehicle accidents, falls and hip fractures can more than double in older adults taking sleep medicines.
- Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age. The American Academy of Pediatrics reminds us that these medicines have little benefit in young children and have potentially serious side effects.
Feel free to browse the list yourself. It is a fascinating gallery of bad medicine. I must confess that I’m guilty of some of the misdeeds myself. I have a handful of older patients who take Ambien (zolpidem). How delighted will they be when I refuse their pharmacy’s request for the next refill and tell them that there are safer alternatives?
Choosing Wisely is a worthwhile effort. It may prevent patient harm and improve care. But I suspect it will not make a dent in costs. As long as doctors have a financial incentive to provide inappropriate care, some of them will. As long as patients have little financial incentive to assure that their care is appropriate, many of them will not.
Medical Waste: 90 More Don'ts For Your Doctor (Shots, NPR’s health blog)
Group Urges Health-Test Curbs (Wall Street Journal)
Doctors list overused medical treatments (Los Angeles Times)
My last post about Choosing Wisely: Healthcare That You Should Avoid
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