Certainly the main goal of health reform was to make sure more people have access to decent medical care. But for the 90%+ of Americans who already have decent access, I’d say that redundant, unnecessary, and just plain over-treatment is a far greater problem. One thing I hope comes out of all the delivery and effectiveness-research reforms embedded in the health law is the idea that more care doesn’t necessarily equal better care; and in fact, more care can often lead to worse health outcomes.
Here’s an item from the NYT on a new type of metal hip replacement that was billed as a vast improvement over the old plastic ball-and-cup types. Though far more expensive, the metal variety swept the nation, and by 2008 accounted for one-third of all hip replacements in America.
In essence, the old technology was repackaged as new and cutting-edge, and warnings like Mr. Black’s were ignored and considered no longer relevant. This new generation of devices was manufactured differently and reflected better designs, advocates argued.
Companies and surgeons began promoting the new implants as the next big step in orthopedics, one that would let patients, particularly middle-age ones, do strenuous physical activities because their mechanics were more natural. And patients, intrigued by ads featuring celebrity athletes, also wanted such devices.
But it turns out that there were big problems with the new method. Apparently the device was so cutting-edge that it sheds metal debris into your blood stream, which in some patients "has caused crippling tissue and muscle damage, and has produced neurological problems in others." The legal fallout is expected to be one of the largest product liability cases of the decade.
And the thing is, it turns out that under the old method, patient outcomes were pretty great:
THE modern artificial hip, which was developed by a British surgeon, Dr. John Charnley, in the 1960s, uses a relatively simple design….By the 1990s, the devices were considered highly effective, with studies then finding that implants still worked a decade after surgery in 95 percent of patients.
As the article makes clear, more careful and rigorous testing of the new hips could have prevented this disaster. But prudence was up against the strong bias of both providers and patients for the new-and-improved:
[I]nnovation’s lure led almost everyone to seize on a product promoted as a breakthrough without convincing evidence that it was better or even as good as existing options.
And here’s the kicker. It’s not just this innovation that has failed make people healthier:
"The vast majority of the ‘innovations’ on which we have spent money with respect to orthopedics over the past two decades have not resulted in improved patient outcomes,” said Dr. Kevin J. Bozic, an orthopedic surgeon and professor at the University of California, San Francisco, who has written about artificial joints’ impact on health care costs.
Why do we keep spending money on interventions that fail to improve patient outcomes? Well our bias toward "the latest and greatest" is certainly one problem. But often, we just have no idea that a certain treatment or procedure is not very effective. And even if we are told as much, we are apt to disbelieve.
For instance, did you know that arthroscopic knee surgery works no better at relieving knee pain than a placebo surgery? Don’t believe me?
In this study, 180 patients with knee pain received arthroscopic debridement, arthroscopic lavage, or simulated arthroscopic surgery in which the surgeon made small incisions without inserting instruments or removing cartilage. All patients randomized to one of these three groups signed an informed consent and were treated by the same surgeon. […]
During two years of follow-up, patients in all three groups reported moderate improvements in pain and functional ability, but neither the debridement nor the lavage group fared better than the placebo group. At certain points during follow-up, subjects receiving sham surgery reported better outcomes than those receiving debridement.
Earlier clinical trials of arthroscopic knee surgery have shown pain relief in most patients but did not compare the actual procedures to sham operations. In the U.S., more than 650,000 arthroscopic debridement or lavage procedures are performed annually, many for arthritis, at a cost of about $5,000 each.
"This study has important policy implications," Wray says. "We have shown that the entire driving force behind this billion dollar industry is the placebo effect. The health care industry should rethink how to test whether surgical procedures, done purely for the relief of subjective symptoms, are more efficacious than a placebo."
(Though an extraordinary result, I don’t know how useful this finding is in practice. Outside of a controlled study, it surely seems a little problematic to have doctors going around giving people incisions but no actual surgery. And even if they could do that, to maintain the placebo effect they’d have to keep the ruse going, charge people for the full surgery, etc.)
This brings up a related issue; what may be termed the Dr. Hibbert/Dr. Nick problem. It’s a quirk of the health care market that there is really no such thing as a "cheaper and less-effective" suite of treatment options, à la Dr. Nick. When people talk about cost control in health care, they’re not saying we should have lower prices and slightly worse medicine. They’re saying we should find a way to make the good stuff cheaper somehow.
That’s not how it works in other markets. With every other consumer good or service, you are expected to decide how much quality/awesomeness you want, and how much you should sacrifice to cost considerations. You can buy a BMW or a less awesome Hyundai. You can buy a huge, clear television, or a less-huge, less-clear one. You can get a very expensive hair cut or go to Supercuts. Car companies and tv makers and salons know that there is a big market for people who just want basic, functional stuff.
But in health care, no such market really exists. Once something better comes along, like the metal hip replacements, the "cheaper, less-good" option soon disappears. Nobody wants it. Nobody is going to choose the Supercuts of heart surgeons, or the Hyundai of oncologists. And while we expect someone with a more modest income to go buy a cheaper car or a cheaper haircut, we all recoil from the notion that that person should be forced to buy a crappier hip or a fake surgery.
But what I hope comes out of health reform over the next several years (I’m skeptical) is that it at least goes some small distance in convincing all of us that sometimes the "crappier" hip is superior, and that the fake surgery is just as good.
