And the majority of waste is not fraud and abuse, but our current system of procedural reimbursement, redundant, unnecessary testing, and unproven treatments.
When I was a medical student, intern and then a resident we were taught to go the distance in order to find the correct diagnosis or render optimal treatment. Ethically there were no other options.
Weighing in heavily was the fact I trained at what would now be designated a tertiary medical center. Patients were referred to our center when their family physician or general internist was stumped in making a diagnosis or referred for an expert treatment or to receive specialized treatment from a specialist who had multiple experiences with a particular disease or surgeries.
Physician outcomes differ radically between community hospitals, amongst themselves and tertiary centers. In some cases outcomes are ‘better’ at a higher level of care for elective surgery And in other cases, such as infectious disease or critical illness, less common acute or chronic diseases they will be worse. Many times incurable illness or those with lower survival rates are referred to a tertiary center.
In this week’s New England Journal of Medicine an article by Howard Brody, M.D., PhD explains the”transition from the ethics of rationing to that of the ethics of waste avoidance”.
(From the Institute for the Medical Humanities, University of Texas Medical Branch, Galveston)
Admirably Dr. Brody does an exemplary, articulate and admirable job of desensitizing an issue that is an emotional conundrum which is rightly anathema to physicians, patients and families.
Rationing is a dirty word….especially in medicine. It conjures up the idea that some patients are worth saving while others are not, and it also conjures up thoughts about “death panels”. This was clearly an anxious moment for Health Reform to remove the idea of a committee of physicians and ethicists making life and death decisions for patients and their families. Clearly, politicians quickly dismissed any idea of ‘death committees’. Any further mention would have doomed “health care revolution”.
To quote Dr. Brody,
A case study for the shift in ethical focus is the treatment of advanced, metastatic breast cancer with high-dose chemotherapy followed by autologous bone marrow transplantation. This treatment was initially thought to offer perhaps a 10% chance of a significant extension of life for patients who would otherwise be fated to die very soon. Insurers' refusal to pay the high costs of this last-chance treatment did much to torpedo public trust in managed care during the 1990s. Data now suggest that the actual chance of meaningful benefit from this treatment is zero and that the only effect of the treatment was to make patients' remaining months of life miserable. In this case, the ethical debate over rationing was misplaced.
We have for too long ignored how much money is spent in the United States on diagnostic tests and treatments that offer no measureable benefit.3 Redirecting even a fraction of that wasted money could expand coverage for useful therapy to all Americans, while reducing the rate of overall cost increases.
The ethical question therefore shifts to waste avoidance. Even though the concept of medical futility has had a vexed history, this new ethical question is a subcategory of the futility debate. We now realize that futile interventions may be administered not solely because of patients' demands but also by physicians acting out of habit or financial self-interest or on the basis of flawed evidence. The ethics of waste avoidance is thus in part a component of the ethics of professionalism.5
The two principal ethical arguments for waste avoidance are first, that we should not deprive any patient of useful medical services, even if they're expensive, so long as money is being wasted on useless interventions, and second, that useless tests and treatments cause harm. Treatments that won't help patients can cause complications. Diagnostic tests that won't help patients produce false positive results that in turn lead to more tests and complications. Primum non nocere becomes the strongest argument for eliminating nonbeneficial medicine.3
Physicians, as loyal patient advocates, must invoke the process when (according to their best clinical judgment) a particular patient would benefit from an intervention even if the average patient won't. Few tests and treatments are futile across the board; most help a few patients and become wasteful when applied beyond that population. But the boundary between wise and wasteful application will often be fuzzy.
Berwick and Hackbarth note a relatively minor ethical point, but a serious policy concern2: a substantial reduction in health care spending would seriously disrupt a $2.5 trillion industry, and thus the U.S. economy as a whole, and would require careful planning and gradual implementation. A stepwise strategy also makes good ethical sense in the face of the current limitations of evidence-based medicine. Given our patient-advocacy duties, it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit. We can then extend the policy gradually as comparative-effectiveness research identifies other sources of waste with reasonable confidence.
An ethical mandate to prioritize waste avoidance doesn't address the political hurdles, of course. Given that one person's health care expense is another person's income, we can anticipate pitched battles, accompanied by demagoguery such as talk of “death panels.” Medicine's role in this campaign will pose a serious challenge to physician professionalism. Will U.S. physicians rise to the occasion, committing ourselves to protecting our patients from harm while ensuring affordable care for the near future?
This fresh approach gives hope to those who are suspicious of what will happen in health reform.
It is critical that patients and physician have voice in ethical decision making, and not become powerless or ‘victims’ of a changing system