Friday, October 31, 2008

Waste, abuse, and fraud, In Health Care: One Man’s Hope is Another Man’s Waste

One man’s meat is another man’s poison.

English Proverb

Both presidential candidates have put forward proposals for curtailing waste in the U.S health care system…But, what really, do we mean by waste?

Henry J. Aaron, PhD, Senior Fellow, Brookings Institute, “Waste: We Know Your Are Out There,” New England Journal of Medicine, October 30, 2008

Health care critics often cast private practice in a negative light. Doctors order too many tests,perform too many procedures, prescribe too many drugs – often for dubious or self-serving reasons. If only we would root out those things deemed to be useless, ineffective, unnecessary, ineffective, duplicate, defensive, and downright venal, we would save $700 billion, 1/3 of money spend on U.S. health care.

Here’s how Henry Aaron, senior fellow at the Bookings Institute, puts it

Reports abound of needless or low-benefit procedures, some performed for fear of litigation, some ouf of venality, some demanded by importunate patients, and some representing the mindless repetition of established routine.

That’s what many pundits believe, and they often offer this answer: Establish a National Institute for Health Care Effectiveness and Health Care Decision Making to decide what works and doesn’t work. Don’t pay for what doesn’t work, and lower all private fees to Medicare levels.

But doctors and patients know health care is not so simple. Much of care is based on hope, that something might work, life might be improved, functionality might be restored even if chances for success are small and costs are high. The operative word is “hope,” not “effectiveness.”

Henry Aaron uses technocratic bureaucratese to define waste, “Waste could be as care that costs more than some threshold per unit of health care improvement,” and he offers this table to clarify what he means.

Probability of Benefit or Harm from Three Hypothetical Medical Interventions.

Intervention Probability Probability Expected Years
Of Extending of Death of Extended Life

By 1 Year, By 5 years

1 0.5 0 0 0.5

2 0.25 0.05 0.7 0.5

3 0 0.1 0.9 0.5

I don’t find this data particularly help, and as Aaron admits, “The very definition of waste is unclear, and the term is fraught with ambiguity.” Low probability procedures may help patients, and besides, as long as someone else is paying, little incentive exists to avoid waste, either among patients or doctors.

What is Aaron’s solution? The first step, he says, is to invest “heavily” in research into what works and doesn’t work, and the second step, is to extend coverage to the uninsured, with limits of spending. He goes on to list these ways to cut costs.

• Carefully analyze cost-effectiveness

• Shift costs to patients

• Free Medicare to extend its spending and regulatory clout to private medicine

• Change physicians’ financial incentives.

• Provide patients with medical homes to improve disease management and coordination.

• Increase use of IT

• Reform insurance markets

None of these measures, he adds, will yield dividends early, and their payoffs are often greatly exaggerated. He concludes “That all these changes would take decades to become fully effective only adds to the urgency of initiating them promptly.”

Aaron’s line of argument doesn’t impress me. Maybe doctors ethics and training to do what is best for their patients isn’t a bad thing. Maybe health care going from 16% of GNP to 20% isn’t a bad result. Maybe health care revenues and their ripple effect are good for economic growth and greater employment in most communities. Maybe most of what doctors decide for patients is clinically sound most of the time, and maybe most of the time what “might” help them is what patients want.

As a surgeon once told me, “I’ve never met a patient who didn’t want to live another day.” Hope springs eternal, and “waste” sometimes has a purpose that cannot be defined in statistical terms.


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