June 22, 2015

What Do Overzealous Roof Repairmen, Car Repairmen And Doctors Have In Common?

As Dossia, my company, increasingly offers valuable navigation tools for plan members to help them get the best value and quality from the healthcare system, I often reflect on the similarities among overzealous tradespeople and overzealous healthcare providers.

My two stories with tradespeople go back to 1980 and 1981, when my wife and I had considerably fewer resources than we have today.  In 1980, we appeared to have a leaky roof that caused a flood of water to gush into our living room via an archway.

Two roofers told us that we had cracked tiles and needed varying degrees of roof replacement, with price estimates ranging from $1,100 to $3,200.  We accidentally discovered that the real problem was a sealed drainage hole under a window sill in our master bedroom, which took about 30 seconds of my time to unseal.  The leak never recurred.

In 1981, our used Volvo 164E inexplicably kept dying when we were driving.  Multiple repair shops replaced batteries, alternators, and even part of our transmission system, often after using exceptionally sophisticated diagnostic equipment.  Ultimately, the problem, which was diagnosed by a small service station in the South Bronx after our car died on the Willis Avenue Bridge, was a $5 fuel filter replacement.

I have similarly experienced overtreatment on medical problems, most recently with a chronic pain problem in my right instep.  After years of going to podiatrists, orthopedic surgeons, and chiropractors, a physical therapist noted that I was not properly lacing my exercise shoes.  After I correctly laced them, the pain disappeared.

What do these cases have in common?

  • We have a chronic or frightening problem.
  • An expert uses an expensive, complicated process to identify something that might be the cause of the problem.
  • We opt for the expensive solution, and it does not work.
  • We finally figure out that the problem is simpler to fix.

These cases are annoying and costly, but there are more life-threatening and stressful examples in our healthcare system.  Laura Landro, a reporter for The Wall Street Journalwrote an article in the June 9 issue entitled “New Ways Doctors Reach Agreement on Patient Diagnoses.”  She cites experts who find that 25% of the tissue and imaging studies done for cancer result in disagreements among practitioners as to both diagnosis and optimal treatment paths.

Similarly, back pain is often over-treated.  Daniel DeNoon, a contributor to the Harvard Health blog, quoted Dr. Bruce Landon of the Harvard Medical School, who pointed out that

“Most routine back pain will improve on its own with conservative therapy in three months, often shorter than that. Even more importantly, when we do more aggressive things—such as injections, imaging, and surgery—the long-term outcomes don’t change at all. These things have very little impact on what is going on, and they have the potential to make things worse.”

Why does over-treatment happen, other than overzealousness and, in many cases, greed by doctors?

  • While the best treatment may be what is called “watchful waiting” for certain cancer diagnoses, because the odds of the cancer spreading are low, many doctors are uncomfortable not appearing to do anything.
  • Patients demand overly aggressive treatment, because they are misguided about the odds of success.
  • There is an insufficient appreciation on the part of the patient or his or her loved ones about the risks of excessively aggressive care, especially in end-of-life treatment cases.
  • Even when both patients and doctors agree that the odds of success are low, especially in terminal cancer cases, patients who are in a very generous health plan are deciding to spend someone else’s money to play the lottery in hopes that they will be among the few to win.

Elected officials, members of the media, and even health plan administrators are not well equipped to say no, especially when the story of an individual who will die without more aggressive treatment is hard to manage.

I experienced this in 1990 after becoming the head of HR for Pitney Bowes.  We had to make a decision whether to approve a high dose chemotherapy treatment for the adult son of a long term employee who would die without the treatment.  The treatment was experimental, and, at the time, we believed that the FDA would approve it.

We approved a $150,000 treatment plan.  The son died, and, unfortunately, we learned later that the high dose chemotherapy was ineffective against the kind of cancer he had.  I would have made a different decision if I had the benefit of hindsight, but it would have been emotionally wrenching to deny the treatment to a dying child.

The one thing I know is that these kinds of decisions do not get made optimally when elected officials, the media, and politically appointed health insurance regulators get into the act.  They also do not get made optimally when the treating physician gets a substantial financial benefit from more aggressive treatment.

Accountable care that is based on quality improvement and cost containment is the best long term solution.  Moreover, educating members of the public that their way of thinking about healthcare is flawed is as critical as educating them about the health risks of tobacco, failure to use seat belts, or driving while intoxicated.  Each of these education processes took several decades.

Similarly, our biggest health problems today are preventable chronic diseases, not acute care situations in which the healthcare system has a magical solution to a life threatening condition that affordable and universal health insurance can solve.

The best thing we can do for ourselves is to create environments in which healthy behaviors are the easiest ones, and we are rewarded for engaging in them.  Hippocrates, the Greek scientist who can be credited as the founder of the medical profession, wisely stated over 2,000 years ago that “Natural forces within us are the true healers of disease.”

Let’s live consistently with his wise observation.