Friday, May 22, 2015

Fwd: qotd: Atul Gawande and the overutilization narrative

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-------- Forwarded Message --------
Subject: qotd: Atul Gawande and the overutilization narrative
Date: Fri, 22 May 2015 06:16:45 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The New Yorker
May 11, 2015
An avalanche of unnecessary medical care is harming patients physically
and financially. What can we do about it?
By Atul Gawande

Could pointless medical care really be that widespread? Six years ago, I
wrote an article for this magazine, titled "The Cost Conundrum," which
explored the problem of unnecessary care in McAllen, Texas, a community
with some of the highest per-capita costs for Medicare in the nation.
But was McAllen an anomaly or did it represent an emerging norm? In
2010, the Institute of Medicine issued a report stating that waste
accounted for thirty per cent of health-care spending, or some seven
hundred and fifty billion dollars a year, which was more than our
nation's entire budget for K-12 education. The report found that higher
prices, administrative expenses, and fraud accounted for almost half of
this waste. Bigger than any of those, however, was the amount spent on
unnecessary health-care services. Now a far more detailed study
confirmed that such waste was pervasive.

I decided to do a crude check. I am a general surgeon with a specialty
in tumors of the thyroid and other endocrine organs. In my clinic that
afternoon, I saw eight new patients with records complete enough that I
could review their past medical history in detail. One saw me about a
hernia, one about a fatty lump growing in her arm, one about a
hormone-secreting mass in her chest, and five about thyroid cancer. To
my surprise, it appeared that seven of those eight had received
unnecessary care.

Virtually every family in the country, the research indicates, has been
subject to overtesting and overtreatment in one form or another.

Another powerful force toward unnecessary care…: the phenomenon of
overtesting, which is a by-product of all the new technologies we have
for peering into the human body.

Overtesting has also created a new, unanticipated problem:
overdiagnosis. This isn't misdiagnosis—the erroneous diagnosis of a
disease. This is the correct diagnosis of a disease that is never going
to bother you in your lifetime.

My last patient in clinic that day, Mrs. E., a woman in her fifties, had
been found to have a thyroid lump. A surgeon removed it, and a biopsy
was done. The lump was benign. But, under the microscope, the
pathologist found a pinpoint "microcarcinoma" next to it, just five
millimetres in size. Anything with the term "carcinoma" in it is bound
to be alarming—"carcinoma" means cancer, however "micro" it might be. So
when the surgeon told Mrs. E. that a cancer had been found in her
thyroid, which was not exactly wrong, she believed he'd saved her life,
which was not exactly right. More than a third of the population turns
out to have these tiny cancers in their thyroid, but fewer than one in a
hundred thousand people die from thyroid cancer a year. Only the rare
microcarcinoma develops the capacity to behave like a dangerous,
invasive cancer. (Indeed, some experts argue that we should stop calling
them "cancers" at all.) That's why expert guidelines recommend no
further treatment when microcarcinomas are found.

Nonetheless, it's difficult to do nothing. The patient's surgeon ordered
a series of ultrasounds, every few months, to monitor the remainder of
her thyroid. When the imaging revealed another five-millimetre nodule,
he recommended removing the rest of her thyroid, out of an abundance of
caution. The patient was seeing me only because the surgeon had to
cancel her operation, owing to his own medical issues. She simply wanted
me to fill in for the job—but it was a job, I advised her, that didn't
need doing in the first place. The surgery posed a greater risk of
causing harm than any microcarcinoma we might find, I explained. There
was a risk of vocal-cord paralysis and life-threatening bleeding.
Removing the thyroid would require that she take a daily
hormone-replacement pill for the rest of her life. We were better off
just checking her nodules in a year and acting only if there was
significant enlargement.

H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on
overdiagnosis, and in his excellent new book, "Less Medicine, More
Health," he explains the phenomenon this way: we've assumed, he says,
that cancers are all like rabbits that you want to catch before they
escape the barnyard pen. But some are more like birds—the most
aggressive cancers have already taken flight before you can discover
them, which is why some people still die from cancer, despite early
detection. And lots are more like turtles. They aren't going anywhere.
Removing them won't make any difference.

We've learned these lessons the hard way. Over the past two decades,
we've tripled the number of thyroid cancers we detect and remove in the
United States, but we haven't reduced the death rate at all. In South
Korea, widespread ultrasound screening has led to a fifteen-fold
increase in detection of small thyroid cancers. Thyroid cancer is now
the No. 1 cancer diagnosed and treated in that country. But, as Welch
points out, the death rate hasn't dropped one iota there, either.
(Meanwhile, the number of people with permanent complications from
thyroid surgery has skyrocketed.) It's all over-diagnosis. We're just
catching turtles.

What if I recommend not operating on a tiny tumor, saying that it is
just a turtle, and it turns out to be a rabbit that bounds out of control?

Mrs. E., my patient with a five-millimetre thyroid nodule that I
recommended leaving alone, feared doing too little. So one morning I
took her to the operating room, opened her neck, and, in the course of
an hour, removed her thyroid gland from its delicate nest of arteries
and veins and critical nerves. Given that the surgery posed a greater
likelihood of harm than of benefit, some people would argue that I
shouldn't have done it. I took her thyroid out because the idea of
tracking a cancer over time filled her with dread, as it does many
people. A decade from now, that may change. The idea that we are
overdiagnosing and overtreating many diseases, including cancer, will
surely become less contentious. That will make it easier to calm
people's worries. But the worries cannot be dismissed. Right now, even
doctors are still coming to terms with the evidence.

Two hours after the surgery, Mrs. E.'s nurse called me urgently to see
her in the recovery room. Her neck was swelling rapidly; she was
bleeding. We rushed her back to the operating room and reopened her neck
before accumulating blood cut off her airway. A small pumping artery had
opened up in a thin band of muscle I'd cauterized. I tied the vessel
off, washed the blood away, and took her back to the recovery room.

I saw her in my office a few weeks later, and was relieved to see she'd
suffered no permanent harm. The black and blue of her neck was fading.
Her voice was normal. And she hadn't needed the pain medication I'd
prescribed. I arranged for a blood test to check the level of her
thyroid hormone, which she now had to take by pill for the rest of her
life. Then I showed her the pathology report. She did have a thyroid
cancer, a microcarcinoma about the size of this "O," with no signs of
unusual invasion or spread. I wished we had a better word for this than
"cancer"—because what she had was not a danger to her life, and would
almost certainly never have bothered her if it had not been caught on a


Comment by Don McCanne

Yesterday's Quote of the Day discussed the harm done by our health care
reform agenda that overemphasizes attacking overutilization while
neglecting more compelling goals of reform. Atul Gawande has been one of
the more credible and outspoken voices in raising the alarm on
overutilization, especially with his widely referenced 2009 New Yorker
article on the excessive use of health care services in McAllen, Texas.
But where does Dr. Gawande stand when he is faced with health care
utilization questions regarding his own patients?

In his current New Yorker article, "Overkill," he describes the
overtesting and overdiagnosis of thyroid carcinoma, which, in turn,
results in overtreatment - all manifestations of overutilization of
health care. For his own patient with a very small thyroid nodule, he
recommended leaving it alone - a recommendation that is well supported
in the medical literature.

Yet, apparently because the patient wanted something done, he elected to
remove her thyroid gland. She did turn out to have a microcarcinoma, but
he reports that it "was not a danger to her life, and would almost
certainly never have bothered her." She manifested two common problems
of overutilization: 1) a post-operative complication (hemorrhage
requiring a second operation), and 2) significant costs that were
unnecessary but added to the very high costs of health care paid by all
of us through taxes or insurance premiums.

Thus Dr. Gawande is himself an overutilizer while preaching the evils of
overutilization. Our current policy priorities are to combat
overutilization. What should be done in Dr. Gawande's case? Should he
and the hospital be denied payment for the thyroidectomy? Should he be
assigned low quality scores that will reduce future payments for his
health care services? Should he be disciplined by the appropriate
medical staff committee? Was his violation serious enough to report him
to the state medical licensing board for consideration of disciplinary

No to all of these. He is a highly respected, ethical surgeon who
certainly tries to do the right thing. He did make a clinical decision
that could be challenged, especially in today's environment where
overutilization is the primary target in health care reform.

Most cases of supposed overutilization as reported in many studies, such
as those from Dartmouth, represent similar judgmental decisions in which
opinion as to the optimal way to proceed would vary amongst the best of
authorities, and Dr. Gawande's judgement in this case falls within the
realm of acceptable medical practices (she did have cancer!).

We do not have and likely never will have processes through which we can
identify, with certainty, medical care that should be aborted in advance
because it clearly would constitute overutilization. Complex clinical
settings defy clarity in health care utilization. (There are exceptions
in which clear guidelines can be established, and those guidelines
certainly should be enforced.)

As mentioned yesterday, designing health policy based on overutilization
has been detrimental because it results in concepts such as
patient-driven health care, especially high deductibles, that have
impaired patient access to beneficial medical care and have exposed
patients to financial hardship. It also has generated concepts such as
accountable care organizations that, to this date, have not accomplished
much more than to increase the profound administrative waste that
permeates the U.S. system.

Our efforts should not be directed to trying to ferret out reputable
physicians such as Dr. Gawande, accuse them of overutilization, and
chase them out of the profession. That could be all of us, and who then
would be left to care for patients? (This is not to say that we
shouldn't rein in blatant abusers.)

Instead we should turn our attention to policies that would would make
health care truly universal, comprehensive, equitable, accessible, and
priced appropriately, while increasing efficiencies through policies
that would actually be effective in recovering waste - the prime example
being the replacement of our expensive, fragmented system of financing
care with an efficient single payer national health program.

Thursday, May 21, 2015

Fwd: qotd: IMPORTANT: The harm done by the overutilization narrative

Quote-of-the-day mailing list

-------- Forwarded Message --------
Subject: qotd: IMPORTANT: The harm done by the overutilization narrative
Date: Thu, 21 May 2015 08:25:54 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Journal of Health Politics, Policy and Law
April 2015
Overutilization, Overutilized
By Deborah Levine and Jessica Mulligan


Overutilization is commonly blamed for escalating costs, compromising
quality, and limiting access to the US health care system. Recent
estimates suggest that nearly one-third of health care spending in the
United States is a result of unnecessary care. Despite the surge of
exposés that purport to uncover this "new" problem, narratives about
overutilization have been circulating in health policy debates since the
beginnings of the health insurance industry. This article traces how the
term overutilization has spread in popularity from a relatively small
community of mid-twentieth-century insurance experts to economists,
physicians, epidemiologists, and eventually the news media of the early
twenty-first century. A quick glimpse at the history of the term reveals
that there has been constant disagreement and debate over the meaning
and impact of overutilization. Moreover, the term has been put to very
different uses, from keeping socialism at bay to preserving the fiscal
integrity of Medicare to protecting the health of patients. The
overutilization narrative, seductive in its promise of cutting costs
without sacrificing access to quality care, too often drowns out other
difficult conversations about social welfare, health equity, prices, and
universal coverage.

Conclusion: Overutilization Has Overreached

For sixty years, overutilization has been a key term in health policy
debates. The term emerged in literature about the potential demise of
voluntary insurance and then spread to new domains: first with inpatient
hospital stays and then eventually with almost every other form of care.
The audience for this narrative expanded as well: from industry insiders
to economists, physicians, public health researchers, the media, and
finally, patients.

Utilization review and other techniques for curbing overutilization like
requiring prior authorization, capitated payments, and increasing
patient cost sharing have now been employed by insurers and providers
for decades. Yet the overall impact on health care costs appears
negligible; costs continue to rise. Moreover, some analysts point out
that the United States may be underutilizing a host of important
services relative to other countries, especially primary care.

Overutilization of certain services probably is one of the many problems
in our health care system. But there are grave consequences to
considering overutilization the central problem. For one, the increased
patient cost sharing that is supposed to rein in overutilization has
contributed to a situation in which 31.7 million people with insurance
are considered underinsured because they dedicate such a high proportion
of their household income to medical bills. And as to the sizable
uninsured population, the prospect of expanding coverage has too often
been cast as a menace to the system rather than a laudable and socially
responsible achievement.

There is a need for a more critical conversation about who wins and
loses thanks to the present system setup. Some work is already happening
in this regard, but it has yet to reach the wide popular audiences and
become "common sense" in the way that overuse has. Academic researchers
have called attention to how much we pay for services and pointed out
that our high prices are largely to blame for runaway health care costs.
Others have argued that risk-pooling techniques need to be resocialized
by turning away from the highly segmented, experience-rated pools that
currently dominate insurance marketplaces. But it is too difficult for
these counternarratives to be heard above the seductive din about
overutilization and the attendant need for individual consumer restraint
that continues to dominate discussions of health care costs in the
United States.

Overutilization is a management neologism that has become an economistic
health policy fairy tale where costs can be cut, services denied, and
hospital days reduced with no harm — financial, physical, or otherwise —
 to patients, providers, or payers. Curbing overutilization alone will
not redeem our health care system. And real people stand to lose when
reducing utilization and increasing efficiency is seen as the primary
goal of health policies.


Comment by Don McCanne

Yesterday's Quote of the Day message on the prevalence of underinsurance
and its consequences, largely caused by the increased use of high
deductibles designed to decrease utilization of health care, is a prime
example of the pervasiveness of the misguided concept that
"overutilization" needs to be the primary target of reform.

Hopefully this article, "Overutilization, Overutilized," will become a
landmark paper in the chronology of health care reform. The concept of
overutilization of health care has driven much of the political and
policy decisions in our reform efforts. This is tragic because it "too
often drowns out other difficult conversations about social welfare,
health equity, prices, and universal coverage," according to the authors.

The policies designed to correct alleged overutilization have not only
been relatively ineffective in reducing spending to a meaningful degree,
often they have also been harmful, impairing access to health care and
frequently creating financial hardships for those with health care needs.

This is particularly shameful when there remains disagreement on which
particular applications of health care are clearly excessive, and
whether they are truly as pervasive as is often claimed. Further, if
this waste is as common as is often claimed, most of it is not
recoverable because of the difficulty of establishing precise guidelines
that can be applied reliably to complex clinical settings.

We have a much greater problem with health care underutilization and its
adverse consequences which are compounded by policies designed to
curtail utilization.

The Abstract and Conclusion above describe the general theme of the
article, but the details are important if we are to turn the reform
process into one that aims to provide health care for everyone, and away
from our current processes that are blunt instruments designed to reduce
utilization while ignoring harm to the patient.

For those who do not have access to the current issue of the Journal of
Health Politics, Policy and Law, this article can be downloaded at the
link above for a fee of $15. It is unfortunate that this article is
behind a paywall, because it does need to be distributed widely.

We need to do all that we can to change the dialogue on reform. Instead
of imperiling our health care system with misguided policies to
haphazardly reduce utilization, we need to advance policies that would
make health care truly universal, comprehensive, equitable, accessible,
and priced appropriately, while increasing efficiencies through policies
that would actually be effective in recovering waste - the prime example
being the replacement of our expensive, fragmented system of financing
care with an efficient single payer national health program.

Let's change the narrative.

Wednesday, May 20, 2015

Fwd: qotd: Rising deductibles will make underinsurance worse

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-------- Forwarded Message --------
Subject: qotd: Rising deductibles will make underinsurance worse
Date: Wed, 20 May 2015 11:08:12 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Commonwealth Fund
May 20, 2015
The Problem of Underinsurance and How Rising Deductibles Will Make It Worse
By Sara R. Collins, Petra W. Rasmussen, Sophie Beutel, Michelle M. Doty


New estimates from the Commonwealth Fund Biennial Health Insurance
Survey, 2014, indicate that 23 percent of 19-to-64-year-old adults who
were insured all year — or 31 million people — had such high
out-of-pocket costs or deductibles relative to their incomes that they
were underinsured. These estimates are statistically unchanged from 2010
and 2012, but nearly double those found in 2003 when the measure was
first introduced in the survey. The share of continuously insured adults
with high deductibles has tripled, rising from 3 percent in 2003 to 11
percent in 2014. Half (51%) of underinsured adults reported problems
with medical bills or debt and more than two of five (44%) reported not
getting needed care because of cost. Among adults who were paying off
medical bills, half of underinsured adults and 41 percent of privately
insured adults with high deductibles had debt loads of $4,000 or more.

Exhibit 2. Underinsured rates among adults ages 19-64 who were insured
all year, by source of coverage at the time of the 2014 survey

20% - Employer-provided coverage
37% - Individual coverage
22% - Medicaid
42% - Medicare (under age 65, disabled)


The rate of growth in medical costs and insurance premiums has slowed in
recent years. However, millions of consumers continue to be saddled with
high out-of-pocket health care costs. While the number of underinsured
people in the United States held constant in 2014, the steady growth in
the proliferation and size of deductibles threatens to increase
underinsurance in the years ahead.

The Affordable Care Act's coverage expansions and protections have
greatly improved the quality of insurance coverage available to people
who lack job-based health benefits. In addition, cost-sharing subsidies
significantly reduce deductibles for people with low incomes who buy
plans in the marketplaces. But those subsidies phase out quickly,
leaving families with deductibles that may be high relative to their
incomes. In addition, the law has only limited ability to improve the
cost protection of employer plans, which is the source of most
American's health insurance.

Reforms and new approaches are needed to improve the cost protection of
health plans. These could include innovations in benefit design that
slow growth in deductibles and emphasize incentives that encourage
people to utilize, rather than delay, timely health care. In addition,
policymakers should identify and address holes in health plans — like
out-of-network physicians in in-network hospitals — which are surprising
many families with unexpected costs. Finally, systemwide efforts to
lower the underlying rate of medical cost growth and share those savings
with consumers will be critical.


Comment by Don McCanne

This update of The Commonwealth Fund's continuing study of the rate of
underinsurance confirms that the problem persists, and the trend of
increasing deductibles may well make it worse.

It is alarming that, since 2003, the category with the most
comprehensive coverage - employer-provided coverage - has doubled the
rate of underinsurance increasing from 10% to 20%. The greatest
contributing factor has been the increase in the use of high deductibles.

Because this study was of individuals insured for a full year, and it
was completed before the end of 2014 - the first year of the ACA
exchanges - the underinsurance rate of enrollees in the exchanges could
not be separated out, and they were included in the category of
individual coverage. In total, 37% of those with individual coverage
were underinsured. This is no surprise since high deductibles have been
used in the individual market in an attempt to prevent premiums from
becoming even less affordable, but this has been at the cost of more
than doubling the rate of underinsurance.

Although we do not have the data yet, we can make some assumptions,
based on plan design, for the trends in underinsurance for those
enrolled in the exchanges. Because of the subsidies for out-of-pocket
expenses for those with the lowest incomes that qualify for the exchange
plans, it is possible that the rate of underinsurance is slightly
reduced for this group. However, for those with moderate incomes,
especially for those who do not qualify for cost-sharing subsidies, the
relatively low actuarial values (percent of costs that the plans cover)
that most exchange enrollees select will likely perpetuate and perhaps
even expand the prevalence of underinsurance. So middle-income Americans
do not escape the risk of being underinsured.

Although Medicaid provides more comprehensive benefits with fewer
out-of-pocket expenses, the very low incomes of Medicaid beneficiaries
leave many of them underinsured since the modest cost sharing that they
do have consumes an excessive percentage of their incomes.

Patients under 65 who receive Medicare do so because of major long-term
disabilities. Since most of them have very limited incomes and other
expenses, and Medicare's comprehensiveness is limited, this group has
the highest rates of underinsurance - 42%. Obviously, when we speak of
Medicare for all, it is imperative that we clarify that we mean an
improved Medicare that has much more comprehensive coverage.

Can this trend be reversed? Can we put in place policies that will
result in reducing or even eliminating the deductibles?

If the plans were to maintain the same actuarial values to keep the
premiums the same while reducing deductibles, the out-of-pocket costs
would shift to those with greater health care needs who already have
enough financial problems. That would defeat one of the most important
functions of health insurance - preventing financial hardship in the
face of medical need.

Another possibility would be to reduce the deductibles and shift the
actuarial values upward, but that would result in sharp increases in
insurance premiums. That would not be acceptable to employers, nor would
it be acceptable to politicians who would have to find revenue sources
to increase the premium subsidies for the exchange plans. It is easy to
cut spending for employers and for the budget hawks in Congress, but it
is almost impossible to reverse the cuts and restore or even expand that

Suppose we leave the higher deductibles in place, but provide enough
subsidies to eliminate underinsurance for everyone. The administrative
complexity alone would make this a very foolish idea. Also when you look
at who is underinsured, you would have to increase the amounts of the
subsidies and expand eligibility to cover many more of the moderate
income individuals in the exchanges, and you would also have to provide
subsidies for those enrolled in employer-provided plans to cover the
increase in deductibles and other cost sharing in those plans. This
would further compound the wasteful administrative excesses that already
characterize our health care financing system.

Do we really need to say it again? A well designed single payer system
would fix this.