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Vol. LXI, No. 8
April 17, 2009

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‘Tidal Wave of Cost’
Perhaps One-Third of Health Care Spending Is Wasted, Says Brownlee

On the front page...

Epic waste of health care dollars is clearly visible from the altitude provided by the Dartmouth Atlas Project, which for more than two decades has tracked trends in health care spending—via Medicare data—nationally. But author Shannon Brownlee, whose award-winning reportage has relied heavily on DAP data, offered ground-level perspective on America’s overtreatment addiction at a Mar. 27 talk in Bldg. 50, presented by the NIH Consensus Development Program.


  Author Shannon Brownlee  
  Author Shannon Brownlee  

“As much as one-third of our health care dollars are wasted,” said Brownlee, a visiting scholar at the Clinical Center’s department of bioethics and the author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. “Health care spending is an enormous problem, a tidal wave of cost…and it is eating up an enormous percentage of our GDP [gross domestic product]. It is not sustainable.”

While there is a perception that aging—the graying of the Baby Boomer generation—is driving up costs, Brownlee says aging “is really not that big a part of the problem.” Rather it is utilization that spurs the spending: Americans tend to think more treatment equals better treatment, and are further seduced both by technology and, in many cases, the authority of the medical profession, despite evidence that much of that intervention is yielding little or no benefit.

“This is true for states, and for individuals,” says Brownlee. “Many Americans don’t perceive how much they are paying” because the costs are hidden behind lower wages and higher prices. “Health care costs average about $8,000 per person, per year, for a total of about $2.4 trillion,” she said, an amount equal to an invisible second mortgage payment for the average family of four.

“What do patients want? That’s another gap in our knowledge. Doctors are not good at figuring it out...It’s not easy to get patients to really understand this stuff—most don’t understand risk, or the difference between absolute and relative risk.”

Brownlee set out to explain why health care costs are rising so rapidly. Using data from the Dartmouth Atlas, which divides the U.S. into 306 hospital-referral regions, she discovered “a great deal of unwarranted variation in the use of medical services.”

Her analysis employed three categories of care defined by Dartmouth researchers: effective, evidence-based care, which accounts for only 12 percent of Medicare spending; preference-sensitive care, which includes elective procedures and tests that should depend on patient choice (“But usually depend on the doctor’s preferences,” she noted) and accounts for 25 percent of Medicare spending; and what she termed “supply- sensitive, or supply-push” care, where 63 percent of Medicare dollars end up.

In this latter category, health care is largely “governed by the assumption that more is better.” For per capita Medicare spending, Dartmouth found geographical variations of 2½- to 4-fold, even among hospitals regarded by U.S. News and World Report as being among the nation’s 77 finest.

But in what she termed the “paradox of plenty,” higher and more costly utilization rates did not buy better care, but worse care, higher rates of mortality, worse communication among doctors and lower levels of patient satisfaction.

“It’s really shocking to patients to hear about this,” she noted. “They think care is based on their need. That’s an illusion.”

Brownlee had much to say about the doctor-patient relationship, which is a sociological tangent the audience was more than happy to follow (both Brownlee and her host, Dr. Barnett Kramer, director of the Office of Medical Applications of Research, insisted at the outset that a fun talk is one that can be freely interrupted by attendees’ curiosity).

“What do patients want? That’s another gap in our knowledge,” she said. “Doctors are not good at figuring it out.” So-called “patient-decision aids,” which are meant to help patients make decisions about their care, are frequently not used, said Brownlee. “It’s not easy to get patients to really understand this stuff—most don’t understand risk, or the difference between absolute and relative risk.”

There is also the effect of white-coat authority: “Patients have a hard time making their doctors unhappy,” said Brownlee. “We try to please them. It’s upsetting to criticize their knowledge, or their caring. I think a lot of patients find this to be true.”
NIH deputy director for intramural research Dr. Michael Gottesman (l) welcomes Gawande to NIH.

Brownlee sets out to explain why health care costs are rising so rapidly.

Other barriers to appropriate care include health literacy (Brownlee says multiple methods, including written, visual and drama-based, are the most effective) and the outmoded notion of patient consent.

“If we’re going to get more high-quality, shared decisionmaking between doctor and patient, then we need informed patient choice, not informed consent,” she argued. “Consent means agreeing to something unpleasant, to permit, or to allow. We need to rethink how we ask patients to say ‘Yes.’ Choice is more active than consent.”

Another barrier to appropriate, evidence-based care is “the general perception that more treatment equal betters treatment, and that more technology is even better,” Brownlee continued. “We tend to equate expense with value, like with cars, restaurants and hotels.”

Other factors driving exaggerated use of medical care include “defensive medicine,” or procedures delivered solely to prevent lawsuits, a “technological arms race,” in which hospitals brag about their latest gamma-knife gizmo or 64-slice scanner, and patient demand.

Another subtle factor is what Brownlee called the “shadow curriculum,” an influential cultural force or ethos that permeates many institutions. “It’s a practice pattern that evolves, but is not related to classroom instruction. It often opposes the wisdom of not doing anything [in a given case].”

Brownlee acknowledges that overtreatment is driven, too, by sheer anxiety and uncertainty.

She concluded with two prescriptions for bending the cost curve in a downward direction: reduce the overuse of acute-care hospitals and introduce “much more organized patient care” (the DAP map showed that the most appropriate levels of care are concentrated in the mountain west and along America’s northern border, an area characterized by large group practices, Brownlee noted); and work harder to ensure informed patient choice, not its passive cousin “consent.” NIHRecord Icon

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