Monday, February 9, 2009

How to Change a Health Care Culture of Excess

We have seen great strides in the decrease of deaths caused by heart disease in the past few decades - better control of elevated blood pressure, still far from ideal, drugs to lower cholesterol and procedures to improve ischemic (not enough blood flow) heart disease.

One of the procedures, cardiac catheritization and stenting, is provided for about a million patients each year at a cost of roughly $60 billion. The question that has recently been posed is, what patients should receive this procedure? The answer, it turns out, is that the procedure should be limited to those with very severe angina (chest pain due to ischemic heart disease), and those with increasing or unstable angina. Drugs alone are quite adequate for the majority of patients who have stable and milder angina.

As a matter of fact, a cardiologist from Miami, Dr. Michael Ozner, has recently published a book, The Great American Heart Hoax, decrying the approximately sixty billion dollar expenditure via overuse of cardiac catheritization and stenting. The science behind the concept that treating the lesions seen on an angiogram is in most cases folly is well documented and accepted by leaders in the field. In spite of this, by far the majority of patients receiving this procedure are in the non-indicated group. Of course cardiology is not the only specialty of excess. Many, if not a majority of medical areas such as end-of-life care, dialysis, orthopedics, oncology etc., combine to create a medical system of inappropriate care with a whopping $600 billion price tag.

Any solution to this problem must be timely, combining medical knowledge with excellent judgment while treating each patient as an individual. This is a task for my local appropriate care committee, salaried and made up of two physicians and a nurse.

For instance: the committee in each hospital would review 50 to 100 charts of patients who had recently undergone catheritization and stenting. Those determined to be unnecessary would require the physicians and the facility (hospital or clinic) to reimburse the third-party payers for these services. This would at the outset require the return of significant amounts of money. This process would be repeated in many areas such as the intensive care units, dialysis, oncology units, etc. The physicians and hospital administrators would quickly learn that inappropriate care is not a good idea. The culture would change overnight and we would have a different medical system.

Monies saved would be more than adequate to properly reimburse primary care and provide universal coverage. No system of saving can be perfect. However, I believe that of the $600 billion spent on inappropriate care, we could save approximately $400 billion. The process would be especially sensitive that any and all care from which a patient could benefit would be encouraged.


David said...

I must object to the idea of making the hospital and providers pay money back retroactively. A more sensible approach would be to warn them the audits will take place and they will be held accountable for any unnecessary treatment from that time forward.

Another source of excess could be the fact that doctors have to "play-it-safe" when treating patients to cover their butt, from a legal standpoint. Maybe you already addressed this in another post, but it seems like tort reform would have to parallel the institution of oversight by an appropriate care committee so docs don't get sued left and right.

Doctor Kenneth Fisher said...

Thank you for your comment, I think the idea of an initial warning is excellent.
One of my main concepts behind an appropriate care committee system that would have congressional backing would be to protect physicians from legal concerns. Although no system can guarantee the prevention of law suits, agreement by senior colleagues would certainly prevent most of them.
If you e-mail me I will by return e-mail send you my policy paper that will provide you with more information about my ideas. Kenneth A. Fisher, M.D.