Conventional health care leaves us Overtreated.

Have you ever wondered why the United States spends 16% of its gross domestic product on health care (a higher percentage than any other country), while it only ranks 37th in performance? That rating comes from the World Health Organization, which evaluates nearly 200 countries according to measures such as life expectancy, access to care, and the cost of care. Journalist Shannon Brownlee has an answer for you. She interviewed top health care leaders, read eye-opening studies in medical journals, and put it all together in a book called Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.

US health care costs so much in part due to wasteful bureaucratic overhead, malpractice, and high prices, Brownlee begins. However, "the most important piece of the puzzle has been consistently overlooked," she writes. "That's unnecessary care. We spend between one-fifth and one-third of our health care dollars, an exorbitant amount of money, between 500 and 700 billion dollars (that's billion with a 'b') on care that does nothing to improve our health."

"This author is as mainstream as they come," says John Weeks, publisher and editor of The Integrator Blog, which offers news and networking on the business, education, policy, and practice of integrative medicine. "When you look at the index of this book, there's nothing under complementary medicine or integrative medicine. She describes how we spend a tremendous amount of money on unnecessary services and that those unneeded treatments are often directly harmful to patients. This is a difficult thing to absorb. It deserves prayerful reflection in conferences and meetings. How can we digest this astonishing reality?"

Too Many Cooks Spoil the Broth

"Anyone who has witnessed the whir of activity in a busy hospital can see how more specialists can lead to more confusion," Brownlee writes. "Each specialist focuses on the part of the body he or she knows best." She describes an 18-month-old child who was in the pediatric intensive care unit at Johns Hopkins for serious burns. After two weeks, the child was moved to a less intensive unit. Then her mother noticed she wasn't doing so well. The child seemed to be extremely thirsty; she sucked eagerly at a wet washcloth. However, the nurses reassured this mother that everything was fine. The next day, her daughter died of dehydration. How could something like this happen in a well-known, leading hospital? "It's difficult to pinpoint exactly what went wrong," Brownlee writes. "A string of tiny missteps led to her death." She points to "the barely controlled chaos of multiple caretakers in an environment where there is little coordination of care."

Brownlee also tells the story of Ann Berwick, who was hospitalized at three different hospitals for a mysterious spinal cord disorder. Her husband, Donald Berwick, MD, observed her care and later wrote about it. The Berwicks experienced a stunning lack of coordination, with various specialists contradicting each other. Ann needed a certain medicine "immediately"; she got it after 60 hours. Each time she was discharged from the hospital, there was very little follow-up care.

Brownlee notes that these problems arise in part because of the way health care services are reimbursed. Physicians and hospitals are paid per procedure. They aren't reimbursed for keeping patients safe or for coordinating their care.

Reimbursement System as an Incentive for Unnecessary Procedures

Because hospitals and physicians are paid for procedures, they have an incentive to do procedures. In many situations, this isn't a "yes or no" question; it's a judgment call. For example, each year about two million people experience invasive cardiology. For those who are having a heart attack, this can be a lifesaver. However, for people with symptoms of mild heart disease, it's elective. "Of 1.2 million elective cardiac procedures, at least 160,000 are inappropriate, meaning they should not have been done according to the cardiologists' own rules for when to put in a stent or do an angioplasty," Brownlee writes. "That's a lot of unnecessary invasive procedures." The latest research suggests that in most elective cases, medications and counseling are just as effective as invasive procedures in preventing heart attacks and death.

Or look at spinal fusion surgery. This procedure is carried out approximately 300,000 times each year, mostly for patients with chronic lower back pain. However, there isn't any reliable research on whether it really works or how it compares to conservative treatment such as physical therapy. Patients often experience continued chronic pain even after multiple fusion surgeries.

On average, hospitals make about $42,000 for each spinal fusion surgery, and the surgeon receives about $4,000 from Medicare, more from private payers. Back surgeons often make one to two million dollars per year. "Many, if not most, surgeons believe they are helping their patients, and they think that the research supports their belief.... Back surgeons often don't understand the meaning of good medical research," Brownlee writes.

Medicare spending varies enormously throughout this country, and a great deal of the variation is in discretionary treatment, relatively minor procedures where there's no hard-and-fast rule stating when the procedure is indicated. One landmark study found that patients with the same medical condition are more likely to die in the parts of the country where Medicare spends the most money. "Spending more means doing more, and doing more increases the chances of errors being committed and of patients being hit with a complication," Brownlee observes.

Brownlee emphasizes that "overall, the benefits of modern medicine far outweigh the risks." She definitely isn't advising people to stay away from hospitals or refuse treatment. She is taking a look at our health care system as a whole and painting a portrait that is different from anything you've seen before: more detail, more color, more nuance. She draws upon a vast reservoir of specialized research and pulls it together in a way the average citizen can understand. "I've been carrying this book around with me and citing sections of it to people," Weeks says. "It's extremely powerful,"

Resources

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer by Shannon Brownlee (New York: Bloomsbury; 2008).

Website: http://www.overtreated.com/home.html.

Website: The Integrator Blog at http://theintegratorblog.com/.

Elaine Zablocki is the former editor of CHRF News Files.