Unnecessary medical care is harming patients physically and financially | Hacker News Reader

Unnecessary medical care is harming patients physically and financially

newyorker.com

77 pointsgoodJobWalrus44 comments

I find it slightly disingenuous to write a comprehensive article on wasteful medical care and yet barely mention the extremely litigious environment that doctors face.

It's not just doctors that remember that one patient that didn't get scanned. Lawyers do, too.

The legal complications around malpractice and malpractice insurance are unfortunate, but they only reinforce the already perverse financial incentives that doctors have for ordering more tests and procedures.

The theme for the article was that doctors need to slow down and spend more time listening to patients. If anything that should reduce the legal risks of inadequate or inappropriate care.

I agree, the financial incentives must be repaired. I just think it is odd that the malpractice angle wasn't mentioned. Dr. Gawande is surely aware of it.

And yes, I'm sure doctors and patients would both agree that docs need to slow down and spend more time listening to patients. As a solution, Dr. Gawande proposes compensation based on quality of care (rather than production). In theory, this seems to make most sense - but I have yet to see a practical way of assessing "quality." What stops doctors from refusing to see sicker patients? Is a doctor at fault if the patient doesn't follow his advice?

The disconnect between ideology and reality in some of these discussions is sometimes remarcable. This "perverse financial objective" you talk about is imaginary. My wife is a doctor. She sometimes lives in fear of not having ordered this or that test. What she pays for insurance could probably support the royal family of some small countries. It's absolutely infuriating that doctors in the US can't focus on patient care and have to worry about being sued out of existence. Imagine if you, as a coder, had to exist under similar conditions.

One of the stats that came out of the Obamacare health care industry discussion in 2009-2010 was that medical tort reform would only reduce medical spending about 1-2% per year.

I think though that that only accounts for the money that would be saved in the lawsuit payouts.

It doesn't include all the costs of un-necessary tests doctors do because they fear getting sued. No matter how big or small the payout in a lawsuit, that's not a good place to be and is going to leave a black mark on a dr's record no matter the outcome.

> For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.

I take issue with that. Here are the statistics for breast cancer and prostate cancer (new cases and deaths) by year: http://seer.cancer.gov/statfacts/html/breast.html http://seer.cancer.gov/statfacts/html/prost.html

The incidence of thyroid cancer has in fact increased, but it was hardly a killer in the first place.

I find the 'turtles-and-rabbits' analogy to be misleading. Plenty of 'turtles' can undergo a transformation and become much faster (at killing you).

Remember, the new cases curve is roughly the slope of the total cases curve. I read your data as more-or-less supportive of the author's claim.

If you want to consider that the statement "We’re treating hundreds of thousands more people each year for these diseases than we ever have" refers to total cases then well, that's always going to be true.

Besides, I am more interested in the statistics of mortality.

> well, that's always going to be true.

unless they die

> I am more interested in the statistics of mortality

"Death rates have not changed significantly over 2002-2012"

Routine screening for breast cancer started in the 80's. http://seer.cancer.gov/statfacts/html/ld/breast.html

Sorry, I really want to understand your point but I am unable. You disagree with the thesis that more intensive screening and identification of these health issues (since the '90s) have increased the number of people diagnosed with the disease, but has not significantly impacted the mortality rates. This seems to be aligned to the stats you quoted. What am I missing?

I don't disagree with the increase in the total number of diagnosed cases, there is nothing to disagree with. I disagree with calling a reduction in the number of deaths since the 90's by half (prostate) and by a third (breast) "a tiny reduction, if any".

OK, but understand that you are also disagreeing with the site you linked itself. Look at the 'data trend' link.

Not trying to be inciteful- kind of a personal issue with me atm, perhaps with you, too.

MD but not an oncologist.

Some of these cases of breast "cancer" would likely resolve on their own if the screening hadn't detected them. We all have "cancer" cells that our body does a pretty good job handling on a routine basis.

Many people would die of something else other than their prostate cancer if we didn't screen for it.

By no means am I saying that screening isn't valuable, it truly is wonderful. However, at some point screening tests get to the point of being too sensitive and causing more harm than good.

"Overdiagnosed" is an interesting read about this topic.

Honest question : how much of the unneeded testing is CYA against ambulance chasers?

I don't know why you are getting down-voted. Among doctors, this is called "defensive medicine," and there is active research about how prevalent it is.

If someone compared a state with low caps on medical malpractice like Texas ($250,000), with other states that don't have such caps you could probably get a fairly straightforward answer.

I don't know how that shakes out. But I do know that various testing companies give kickbacks to doctors in the form of leasing office space from them at far above the market rate so their people can give on-premise 'consultations' on which tests need to be done. Among other abuses.

At any rate, I think the financial incentives that exist in the medical sector and how those incentives align with the patient need, desperately, to be addressed as forthrightly and quickly as possible. But there seems to be a taboo around suggesting that doctors are human and are susceptible to the influence of money as anyone else.

The US has excellent medical research, advanced technology, etc. But also extremely inefficient system, about 2x the cost of comparable countries.

- http://www.theguardian.com/news/datablog/2012/jun/30/healthc...

- https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

I find this article interesting in the light of recent passing of Dave Goldberg, when most of the commentators got on to "please folks see your doctor", even if you are healthy, bandwagon.

There are good reasons to see your doctor periodically even if you feel fine. It's a lot easier to treat diabetes and hypertension before they become symptomatic than it is to find you a new kidney.

The current world is medicine is kind of frightening. How many of us would just dig into writing a program after a 15-minute conversation with a client?

What are you talking about? Are you suggesting it's bad that doctors presume knowledge about your health issues after a short visit?

I'm saying that they're not spending enough time with patients before doling out treatment.

It's more akin to spending 8 to 10 years writing a program (med school + residency +....) and then it takes 15 minutes to run the program for the individual instance

But the article describes (and my own experience has been similar) patients being ignored because the doctor's made up his mind and it's on to the next patient without any time to stop and look at this particular patient's circumstances.

The WellMed system described in that article was interesting. Most doctors (especially primary care) do want to spend more time helping fewer patients, but the financial incentives push them in the opposite direction. If the ACA's Pay-for-Performance experiments work out then hopefully we will be able to properly incentivise healthcare.

I agree; that was encouraging.

Horrible analogy is horrible

Care to elaborate?

Sweet, now we can also file malpractice suits against the doctors that order tons of covering-their-asses tests!

A third-party payer system, such as Medicare, has no incentive to keep costs low.

Medicare is among the best at keeping prices low, but none of this is even relevant to the article, if you'd read it.

this may be true, but when a doctor finds out you are on medicare versus say, paying cash, they add on a few extra procedures just to bill the gov a bit more.

source: i work in healthcare.

The same happens with private insurance. I think your point would have been better if you had written "Medicare or health insurance"

agreed, good point.

That's an absolutely ridiculous statement. As a Canadian myself, we are constantly seeing the struggle to reduce the cost of providing health care as a proportion of the taxes we pay.

I don't know where this myth comes from -- is it just a misunderstanding of how public health care works, assuming that it's an infinite money pit?

It comes from motivated reasoning.

It comes from buying into the anti-government propaganda that the hard right has been pumping out for decades.

Once you buy into that, you start applying that faulty reasoning to the real world, and you come up with afactual claims like the original poster did.

Medicare has an incentive to keep prices low, which is demonstrated by the fact that in many (most?) cases it reimburses providers at less than their cost.

Perversely, it also raises costs by increasing demand for medical care.

Maybe in Libertopia, but, on the other hand, actual reality.

Wow, I sure got slammed for what I thought was a self-evident comment. I'll give one true example why I believe this. I was injured and the doctor said I needed an MRI and prescription pain meds. I said, doctor, I don't have insurance. He said, in that case, you can have an X-ray and Tylenol.

This is true for Medicare and private insurance. Think about it. You buy a car based on how much you can afford. If I offered to buy you any car you wanted regardless of price, you would pay much more for a car than if you yourself had to pay. If this were true for everyone, auto dealers would no longer have to compete on price, but would instead would compete on giving the best service, raising costs even further.

Historically, health care costs began to greatly rise when the federal government made it a tax deduction for employee health insurance. This pushed everyone into private insurance. Costs have spiraled ever since. The solution (as proposed by both candidate McCain and candidate Romney) is to shift the tax deduction to the individual for medical costs. This allows people to afford health care, but also introduces competitive market forces (from a first-party payer) into the equation.

If I offered to buy you any car you wanted regardless of price

Except that's not what Medicare does. You may not have an incentive to get the cheapest treatment, but the people running Medicare do have an incentive to keep costs down, and the power of law to do so.

As someone who has had to fight to get tests which later turned out to be critical, I can't help but wonder we're seeing more articles like this one just as the government, having assumed much more control of the health care system, is desperate to find places where costs can be reduced.

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