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In Delivering Care, More Isn't Always Better, Experts Say

By Ceci Connolly
Washington Post Staff Writer
Tuesday, September 29, 2009

A dirty word in health-care reform is "rationing," a term that conjures up the image of faceless government bureaucrats denying lifesaving therapies in the name of cutting costs.

But what if the real issue is not the specter of future rationing, but the haphazard, even illogical, way in which care is delivered today?

Medical professionals say the fundamental problem in the nation's health-care system is the widespread misuse and overuse of tests, treatments and drugs that drive up prices, have little value to patients, and can pose serious risks. The question, they say, is not whether there will be rationing, but rather what will be rationed, and when and how.

"More is not necessarily better," said Bernard Rosof, chairman of the board of directors of New York's Huntington Hospital and a board member of the independent National Quality Forum. "In many cases, less is better."

When the Senate Finance Committee resumes its consideration of health-care legislation Tuesday, the lawmakers will be wading into one of the most complex, emotionally charged aspects of today's $2.4 trillion system. Democrats, feeling politically singed by this summer's talk of "death panels," are struggling to explain how a bill that would take hundreds of billions of dollars out of the system would not affect care.

Republicans, sensing a political opening, intend to highlight provisions they say could lead to the denial of medical services, or rationing.

"We don't want to turn health care over to a bunch of bureaucrats in Washington, who then will determine what kind of health care we have," committee member Orrin G. Hatch (R-Utah) said recently. "And you know that rationing is going to happen."

Critics of the Democrats' bill cite places, such as Canada and Europe, where government experts prioritize the delivery of medical services. Wait times, particularly for specialists, may stretch for weeks or months under such a system, they fear.

"Here in the States, we get access to new drugs and medical devices," said Canadian-born Sally C. Pipes, president of the market-oriented Pacific Research Institute. "I have friends in Vancouver who can't get colonoscopies; they wait six or seven months."

Others, however, see problems of misalignment in the American system, fueled by industry advertising, physician fears about malpractice lawsuits and a culture that craves the latest, greatest everything. The situation here, they argue, is that there is not enough care for some, and too much for others.

Often, people with generous insurance plans can run up large bills and face life-threatening complications from unnecessary care: back surgeries that result in wound infections, when physical therapy might have been a more effective treatment; imaging scans that expose patients to radiation; medication-caused side effects that must be treated.

As much as $850 billion spent on medical care each year "can be eliminated without reducing the quality of care," according to a 2008 report by the New England Healthcare Institute. That is enough money to extend insurance coverage to more than 30 million people, according to the Congressional Budget Office.

The misuse and overuse runs from simple antibiotics to sophisticated surgeries, Rosof said. More than $58 billion is spent on inappropriate drugs, such as antibiotics for upper respiratory infections that do not respond to medication, according to the institute report. About $21 billion is spent treating non-urgent cases in the emergency department, where physicians rely more on duplicative and costly tests because they are unfamiliar with their patients' histories.

The largest potential area for savings -- up to $600 billion a year -- is the great "unexplained" variation in hospital procedures such as the number of Caesarean sections and coronary bypass surgeries performed. Vaginal delivery is far safer than a C-section, and prescription medicines can stabilize many heart patients without dangerous surgical complications, Rosof said. Less invasive and risky alternatives are also less expensive.

"We will eliminate a lot of harm that comes from the overuse and inappropriate use and misuse of medical interventions," he said. "This is not about rationing. This is about practicing evidence-based medicine."

In theory, Joseph Antos, a health policy scholar at the American Enterprise Institute, agrees. One classic example, he said, is the widespread use of full-body scans "by middle-class people who are probably a little neurotic."

"If they want to spend their money on that, that's fine. If they want to spend our money on that, we ought to think about it," he said. "The problem is, there are very few examples of things like full-body scans where it is a no-brainer. When you get down to the specific individual cases, it's very difficult."

In a world of finite resources, it is logical to worry about rationing, said Mark V. Pauly, a professor of health-care management at the Wharton School of Business in Philadelphia. Making greater use of advanced practice nurses is one way to trim costs and maintain high quality, he said. But he suspects there are few instances of such "low-hanging fruit."

Many others express confidence that better data on what works and greater use of electronic medical records will help physicians deliver high-value care. But the shift will also require changes in payment incentives, malpractice laws and, ultimately, cultural attitudes.

In today's system, doctors face increasing pressure to perform expensive tests and procedures they know may not be necessary, or even advisable, said Arthur Kellerman, an associate dean at Emory School of Medicine in Atlanta and a physician at that city's Grady Memorial Hospital. Patients routinely arrive in the hospital's emergency room complaining of a headache and asking for a CT scan. Though the costly scan can help detect tumors and aneurysms, Kellerman counsels against it, explaining the risk of radiation exposure.

"We can always revisit it down the road if the problem persists," he tells the patient. Kellerman has just rationed care. But, he maintains, it is the right kind of rationing, based on known benefits and risks. And reducing traffic in the ER helps free up beds, machines and doctors to treat the true emergencies.

As he put it: "In the United States today, we give you all the care you can afford, whether or not you need it, as opposed to all the care you need, whether or not you can afford it."

Research editor Alice Crites contributed to this report.

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