This is the first of a five-part series titled “Diagnosis Overkill.”
Business and technology trends are disrupting the medical diagnosis as we know it.
“Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.” – Dr. Atul Gawande, Overkill, 2009
In the summer of 2015, Dr. Atul Gawande wrote about the epidemic of unnecessary care in the US. Due to a combination of defensive medicine, entrenched business practices, shifting medical guidelines, and a host of other factors, he wrote, Americans are getting overscreened, overdiagnosed, and ultimately, overtreated.
Dr. Gawande’s prognosis bears reflection. You may be familiar with parts of his ongoing thesis on value in healthcare industry; his 2009 essay on hotspotting famously became required reading in Obama’s White House. As a surgeon, caregiver, and academic journalist, he wove a story driven by statistics and patterns in utilization and outcomes data, which served as a catalyst for the national conversation about the unnecessary volume of care in American healthcare. Some of those numbers bear consideration:
- On average, every American receives one misdiagnosis in their lifetime, according to the Institute of Medicine (IOM)
- Medical care is the third-leading cause of death in the US, taking into account drug interactions, hospital acquired infections, and other inappropriate treatment
- 10 percent of patient deaths and 17 percent of adverse events in hospitals are thought to be attributable to such errors
- 5 percent of US outpatient visits, or about 12 million visits per year, involve a diagnostic error according to conservative estimates
- “About half” of those 12 million errors “have the potential to lead to severe harm,” according to the British Journal of Medicine (BMJ)
That’s roughly six million potential cases of harm attributable to unneeded care. Even if we set aside the whole “do no harm” thing for a moment, health economists have been teasing apart the business case for doing better by doing less for years. Medical costs are still the number one reason Americans declare bankruptcy. Wonks estimate that overtreatment leads to $750 billion in unnecessary costs each year, which adds up to about a third of our nation’s overall healthcare spending.
Are we there yet?
The volume-to-value shift became one of the central themes of the Affordable Care Act. It directly and indirectly launched hundreds of Accountable Care Organizations (ACOs), which penalize hospital systems for inefficiency and error and reward them for hitting quality and cost benchmarks. ACOs were built on evidence generated by smaller, practice-level models called patient-centered medical homes (PCMH), which had been successful in managing costs and quality at some of the nation’s leading delivery systems. From Dr. Gawande’s perch in 2015, the overtreatment problem had a far rosier short-term prognosis; ACO’s were growing in number and maturity, and the industry had started sending the right signals about adopting new models behind leadership from Washington.
But, where in 2015 value based care seemed like a silver bullet, in 2017 it’s turned into a grey cloud. Today the ACA faces, at best, an uncertain future; with all of the uncertainty in Washington DC, health systems and payers alike have shifted into wait-and-see mode. Yet, even if the ACA makes it through all of the ongoing federal drama, the US healthcare system will remain woefully inefficient due to forces more powerful than political legislature.
While federal policy isn’t the only path to improving healthcare costs and outcomes, it isn’t the only obstacle, either. Business, technology, and science are ratcheting up the rates of diagnosis and treatment in ways completely unrelated to traditional healthcare delivery.
The business side of the patient-doctor relationship has become far more multifaceted than the traditional gatekeeper model was built for. Technologies throughout healthcare, from medical devices to chatbots, are making it far easier than ever before to generate diagnoses. And while business practices and emerging tech promises to perpetuate the trend of overtreatment, the genomics revolution will disrupt the entire concept of a medical diagnosis as we’ve known it.