When More Isn’t Better
WHY YOU SHOULD CARE
Unnecessary medical tests and procedures aren’t just a waste of time and money. They may actually harm you.
This Christmas, the McMaths celebrated with the usual tree, presents and games. But they took their festivities to the Children’s Hospital & Research Center in Oakland, California — where 13-year-old Jahi McMath remains on life support. Soon after she had her tonsils removed to treat sleep apnea, a common breathing disorder, the eighth grader bled uncontrollably from her nose and mouth and went into cardiac arrest, cutting off the oxygen supply to her brain. A California judge declared her brain dead on Christmas Eve.
But tonsillectomies aren’t the only procedure worth questioning. In fact, 10 to 20 percent of surgeries aren’t necessary, according to a USA Today report. These not only waste time and money but may also harm patients. What’s more, hospitals could be profiting more from botched surgeries than those that run smoothly because they often require additional care.The tragedy has drawn scrutiny over the need for that particular surgical procedure. Although some clinicians believe a tonsillectomy can be effective for treating pediatric sleep apnea, others believe more research is needed. “It’s a silent epidemic of unnecessary care,” said David Goodman, a professor of pediatrics at Dartmouth University. “In most instances, [tonsillectomies are] done for patients with much less recurrent symptoms than should be indicated.”
10% – 20%
Percentage of surgeries that are unnecessary
A study published last month in the New England Journal of Medicine found that a common procedure to repair the meniscus — a disk of cartilage that helps cushion the knees — worked no better than a simulated surgery. The real surgery shaved damaged cartiilage. The simulated version simply used shavers without blades, rubbing them against the kneecap’s outer surface to mimic the feeling. A year later, most patients in both the real and sham surgery groups said their knees felt better. Around the same time, the Annals of Internal Medicine reported that many women who are diagnosed with breast cancer unnecessarily opt to have their healthy, unaffected breast removed. Only about half of those surveyed reported that their doctors had even discussed reasons not to have the mastectomy.
Annual Pap tests in women 30 to 65 years old. In average-risk women, yearly Pap tests for cervical cancer offer no advantage over screenings every three years.The medical community has taken notice. A coalition of 25 specialty societies recently launched the Choosing Wisely campaign to rally against unnecessary care, urging patients to question the routine use of 130 tests and treatments, including:
- Automatic CT scans to evaluate minor head injuries in children. CT scans can increase cancer risk in children, whose brain tissue is more sensitive to radiation.
- Cardiac stress tests in healthy individuals. Even though stress tests are usually safe, they may produce false-positive results, leading to unnecessary follow-up tests that expose patients to more radiation.
- Electroencephalography (EEG) for diagnosing headaches. EEG offers no advantage over a doctor’s exam, doesn’t improve outcomes and increases costs.
- Feeding tubes in patients with advanced dementia. Studies have linked these to increased risk of ulcer and emotional distress.
Hospitals can rake in huge profits from these services — even when they go awry. A study in the April issue of the Journal of the American Medical Association found that hospitals make about $30,000 more from patients whose procedures lead to at least one complication than they do from complication-free procedures. Why? Because insurers pay for the longer stays and extra care needed to treat surgical complications that could have been prevented.
Additional profit from surgeries that result in at least one complication
No one is saying that hospitals deliberately botch surgeries. But the current health-care system offers little incentive for hospitals to improve — in fact, they may actually lose money doing so, according to the study.
Meanwhile, the fee-for-service model rewards hospitals for quantity rather than quality of care, and many doctors don’t realize how much their services cost, said Daniel Wolfson, vice president of the Choosing Wisely campaign. What’s more, doctors often lack the communication skills to talk to patients about their care.
But patients also need to take responsibility and ask questions about why a treatment is necessary and whether there are alternatives, Wolfson added. However, he noted that Choosing Wisely’s recommendations are just that. “They’re not absolutes,” he said. Instead, they suggest procedures that patients and doctors should “have conversations about.”
The good news? Obamacare’s Bundled Payment Improvement initiative might help matters by reimbursing about 500 participating health-care organizations a lump sum for all the services provided for a specific condition or a set period of time. A lump sum could discourage hospitals from ratcheting up the number of follow-up visits or procedures if they aren’t being reimbursed for each one.
“We’re trying to move from ‘Why didn’t you order that?’ to ‘Why did you order that?’” Wolfson said. “Getting more treatment isn’t always better.”
*Editor’s note: An earlier version of this article did not adequately credit a source, The New York Times.