Doctors, patients, and health plans are cranking up the pressure on the Institute of Medicine as it prepares its recommendations on the "essential" benefits health plans should cover under the healthcare-reform law. The outcome will have a big impact on costs -- not to mention on patient well-being.
Unfortunately, the exercise will have only a limited impact in reforming healthcare. Until policy makers address much bigger problems -- namely the continued prevalence of deadly medical error and the fact that we still don't know which treatments work best in far too many cases -- waste and cruddy medical care will continue to be huge issues for the healthcare system as a whole.
One hopeful sign: Donald Berwick, administrator of the Centers for Medicare and Medicaid Services (CMS), promises that CMS will soon launch a big safety initiative to reduce healthcare-related complications. The Center for Medicare and Medicaid Innovation (CMMI) is also supposed to fund programs and technologies that result in less expensive care without detracting from quality.
Perhaps CMMI will come up with incentives to get physicians to make practice changes in response to new medical studies. But in the meantime, there's a daily drumbeat of disheartening reports about the gap between theory and practice in medicine.
In just one recent day, there were news stories about the widespread misdiagnosing of Alzheimer's disease, needless biopsies of patients suspected of having prostate cancer, cases of people contracting HIV during colonoscopies, and incidents in which babies received whole body irradiation instead of targeted X rays. Here are some snapshots of a healthcare system run amok:
- At Downstate Medical Center in Brooklyn, NY, some infants received full-body scans instead of being shielded from x-rays except in the targeted areas. The reason: poor training, oversight and regulation of imaging technologists. Something similar happened a few months ago in Michigan, where four patients received many times the recommended dose of radiation during cancer treatments.
- Miami-area veterans who had colonoscopies at the VA hospital in that city are at risk of contracting HIV or other infections because of contaminated equipment. So far, five Miami-area vets who had colonoscopies at the VA between 2004 and 2009 have tested positive for HIV, eight for hepatitis C and one for hepatitis B. More than 2,500 people are at risk of infection, according to the agency. About 150 lawsuits have been or will be filed.
- In a recent study in Honolulu, researchers autopsied the brains of Japanese-American men who had died after being diagnosed as suffering from Alzheimer's disease. About half of the men had something else, and some of the conditions they had -- unlike Alzheimer's -- were treatable. If physicians were better trained in the diagnosis of these conditions, many patients would do better and live longer.
- Some physicians order needle biopsies of men to look for prostate cancer when their PSA score suddenly spikes, even if it remains in the normal range. A new study shows that this practice doesn't catch aggressive cancers and results in many unnecessary biopsies. If every doctor ordered biopsies whenever PSA levels rose suddenly, the lead researcher pointed out, one in seven men would undergo these invasive tests. I might add that the literature still doesn't show that PSA tests lower mortality from prostate cancer, yet many doctors routinely order them.
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