This is the second installment of a five-part series titled “Diagnosis Overkill.”
Why are so many Americans getting diagnosed and treated inappropriately in the first place? Dr. Hardeep Singh, a leading researcher in this space, breaks down how the process of diagnosing a patient can be broken down into five components.
These structural descriptions reveal a set of deep-rooted challenges that should be familiar to any health reformer: Behavior change, cultural shifts, and incentive realignment among doctors and clinical caregivers at every level. At a system level, the aggregation of enough communication errors, missed passes, misinformation and the like add up to a rash of inefficient treatment patterns, which Dr. Gawande pinned on the map in places like McAllen, TX and Camden, NJ.
Some of these errors go deeper than a surface level fix. Journalist David Epstein explores the pervasive culture of overtreatment in a jarring critique of medical science, training, culture, and behavior. Even when they know better, when they’re in the trenches of an episode of care, patients and doctors alike gravitate towards “doing something” as a rule of thumb.
As one doctor said to another in Epstein’s piece: “Look, save yourself the headache, just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery. Just do the surgery.”
That’s a surgeon, talking about surgeons encouraging surgeons to err towards surgery when a patient comes in looking for a medically unnecessary surgery.
This isn’t about pointing fingers at a few bad actors. It’s about a culture of business medicine in which everyone, patients included, is hardwired to certain assumptions about the value of services, treatments, transactions. This is the reality that ACOs are nibbling around the edges of; it’s why “reform” and “fix” are two different words in the world of healthcare.
When a culture of volume is hardwired into the very organizations and people, bandaid policies won’t suffice. Health system consolidation aims to improve regional market share among patients through ratcheting up the volume of services they offer, continually adding to the number of facilities on the map, and winning patients’ mindshare through marketing and network dominance. Despite the growth of value-based contracts, clinicians are always encouraged to operate in a selfish incentive paradigm wherein surgical centers of excellence and expensive diagnostic tests still drive revenues. It’s no different from corporate consultants, car mechanics, or your neighborhood pizza joint. In business, doing more is always better.
On the flip side of the coin, health insurance has been shifting away from the tight gatekeeping practices of the HMO model for over two decades now. PPO plans, popular among employers, encourage the commercially insured to seek out the care they want rather than wait for a primary care doctor to make a diagnosis and referral. While plans with higher deductibles and out of pocket payments have been touted as a way to reduce utilization, ample studies show that these plans can discourage high-value preventative care, e.g. screenings for common cancers.
In part this dysfunction arises from needlessly complicated benefit designs, a pervasive lack of consumer-friendly access, low rates of health literacy and education. But more simply, as Dan Munro is fond of pointing out, “The System was never broken. It was built this way.” All of this is to say that while better clinical workflows will help curb some of the diagnostic error that Dr. Singh points out, such peripheral reforms are akin to using a scalpel where we might need a bone saw.
Unfortunately as it turns out, more precise tools might not be the answer, either.
Old Doc, new tricks
A new wave of hardware gizmos is making it easier, quicker, and more cost-effective for physicians to make diagnoses. These medical devices aim to generate clinical grade, reliable diagnostic data at smaller sizes and prices:
“Other devices, such as mobile ultrasound scanner Lumify, made by Philips, delve even deeper into the human body. Last January, [Dr. Eric] Topol tweeted images of a head-to-toe smartphone ultrasound he performed on himself using the device — every organ from his thyroid, gall bladder and aorta, to his kidney, spleen and liver was imaged exquisitely via his phone. “It’s $199 per month for unlimited use, compared to a $350,000 ultrasound machine in a hospital,” he says. “To me that’s revolutionary. I’d use it for every patient in my clinic.”
Dr. Topol’s enthusiasm for digital health tools is well known. But hospital systems aren’t going to fall out of love with the big, expensive imaging toys that still drive billing and revenue. Industry forecasts predict year over year growth of imaging machinery through the end of this decade, driven by increased screening rates, higher specialization, global growth, and other factors. Recent GOP efforts to include a repeal of the medical device tax in the ACA replacement bill highlight how influential the medical device lobby is at a federal level. Suffice to say we’re not likely to see fewer MRI machines anytime soon, even as more advanced equipment begins flooding the market, one trade show at a time.
That’s the rub: Making diagnostics easier and cheaper just means we’ll simply wind up doing a lot more testing with all of the new medical devices that the industry cranks out over years to come. It doesn’t guarantee that the overall rate of testing becomes more accurate, more holistic, or more effective. Ironically, it was a younger Dr. Topol himself who pointed out an emerging trend of overtreatment by cardiologists in the 1980’s:
“Topol coined the term, “oculostenotic reflex.” Oculo, from the Latin for “eye,” and stenotic, from the Greek for “narrow,” as in a narrowed artery. The meaning: If you see a blockage, you’ll reflexively fix a blockage.”