In a recent post on KevinMD, consultant Joe Paduda opined that, in return for getting millions of new members under healthcare reform, health insurers should "manage care and control costs" better. Doctors, of course, aren't usually inclined to listen to insurance suits in the first place. Even if that weren't the case, there are some serious obstacles to convincing both doctors and patients that less can sometimes be more.
For example, the preponderance of evidence shows that prostate-specific antigen (PSA) tests to detect prostate cancer don't reduce mortality and that the harm caused by false positive results from these tests may outweigh their benefits. The U.K. National Screening Committee, which advises the U.K. government and the National Health Service about preventive care policies, recently recommended against doing routine screening of men using the PSA test -- although the committee added that doctors should give the test to any patient who requests it.
There is unlikely to be an outcry against this policy in the U.K., where people realize the necessity of limiting healthcare in order to keep it affordable. But in this country, such evidence-based studies haven't changed the basic approach to prostate cancer screening. Although the U.S. Preventive Services Task Force says there's insufficient evidence to recommend the PSA test for men under 75 and that it should not be ordered for men 75 or older, many physicians continue to order PSA tests routinely for men over 50. As a result, some men undergo more expensive, invasive tests and worry pointlessly because of false positives related to benign conditions.
More serious consequences can befall elderly patients who are subjected to needless procedures when they face life-threatening conditions. President Obama, for instance, recalled that his grandmother received a hip replacement just two weeks before she died from complications of cancer. Obama said he would have paid for that operation himself. But he noted that it was a "difficult decision" to determine whether the collective decisions of people with terminal illnesses to have such procedures is "a sustainable model."
Citing that anecdote in a recent New England Journal of Medicine article, anesthesiologist Mark D. Neuman observes that these days, few patients are considered "too sick" to operate on. The next phase of healthcare reform, Neuman says, is "improving the way that physicians approach decisions to recommend for or against medical and surgical procedures whose potential benefits may be equivocal."
It's a good goal, but one that won't be easy to achieve. Neither surgeons nor professors of surgery are likely to turn their backs on the technologies that have made them rich and successful, and they don't often feel comfortable deciding not to do procedures that they can perform safely. Our entire medical philosophy -- not to mention the medico-legal system -- is pitted against it. And yet, until patients and doctors can agree that certain tests and procedures make no sense, we have little chance of controlling healthcare costs.
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