The New Health Dialogue

PHOTOGRAPH BY: BENN GROVER, EDITOR PROCOR

Vikas Saini, M.D. is a clinical cardiologist and researcher at Harvard Medical School and Harvard School of Public Health and president of the Lown Cardiovascular Research Foundation in Boston. This article is cross-posted in the Lown Foundation's Prevention India column. For another perspective on avoiding avoidable care, check out Shannon Brownlee's accompanying piece entitled, "Less is More."

We need to reduce overdiagnosis and overtreatment and use the costs associated with them to pay for prevention.

Prevention works, but prevention costs money. Some prevention can be practised at the individual level as is emphasised by the content of this magazine. Much of the prevention opportunity lies at the social level—whether in the provisioning of parks and recreation areas for exercise, or regulation to make food safe and healthy. But all of this, whether at the individual or social level, costs money. In a world of constrained resources, where will the money come from?

The Case Against Overtreatment

The United States has been exporting a high-technology medical model which is resource intensive. The widespread adoption of it in India will be a fiscal drag on socially equitable growth. Make no mistake—there are diseases and conditions for which acute, heroic medicine is life-saving. In my field, one excellent example is the practice of emergency angioplasty and stenting for acute heart attacks. Here, the benefit requires rapid intervention within the first few hours of symptoms. Unfortunately, most angioplasty and stenting in the United States today is not done for these cases, but for ‘routine’ or elective procedures for stable symptoms. When their doctor offers this to them, most patients do not realise that they will not live longer or prevent a heart attack by having this costly procedure in this setting. Now there is a movement building in the US to begin to highlight the problem of ‘overtreatment’ or avoidable care. Recently, the prestigious Institute of Medicine of the National Academy of Sciences issued a lengthy report on the topic. Using careful methods to estimate the amount of unnecessary costs in the US, their expert panel came up with a judgement that nearly one third of health care costs in the US are avoidable. Of these, a big portion is from overdiagnosis and overtreatment.

Reasons for Treatment Abuse

There are many innocent factors such as confusing scientific evidence, fear of law suits, fragmentation of care, and lack of patient involvement in the decision-making. But the largest factor in my opinion is the fee-for-service system of payments to doctors, who get rewarded for high volume rather than high value, enabled by the belief of patients that ‘everything should be done’. For patients, the worry about health trumps everything and makes careful thinking in the anxious moment nearly impossible. After all, ‘the doctor knows best’. My familiarity with the Indian health care system is slight, but what little I have learnt concerns me. Doctors have little incentive to avoid unnecessary care, and plenty of reasons to tout the latest gadget and charge high fees for multiple tests and procedures. And I must say that all human beings everywhere in the modern world seem to be hypnotised by the magical belief that getting ‘all the tests’ is the sure path to a cure. So making the case for another CAT scan, PSA test or nuclear treadmill ‘just to be sure’ is relatively easy for the doctor and hard to resist for a patient. After all, how can a lay person argue whether a test is necessary or unnecessary.

While the responsibility for appropriate usage of tests and technology lies with physicians, you can participate in the decisionmaking process armed with awareness and information.

A Way to Cut the Burden of Overtreatment

The responsibility for appropriate usage of tests and technology lies with physicians. What is needed is genuine leadership and proper education on the issues—along with the elimination of conflicts of interest. My own view is that the best way to do this is to organise medical practices into larger groups with doctors on salary and with minimal hospital control. At the Lown Foundation we are currently working with several institutions to organise a coherent movement of concerned clinical leaders throughout the US to begin to spread the word. We are discovering an army of like-minded allies who want to help. Hopefully our message will be heard and heeded in the US and around the world.