Overtreatment In The United States Health Care

System
Posted on October 24, 2017 by Lambert Strether

https://www.nakedcapitalism.com/2017/10/overtreatment-united-states-health-care-system.html

By Lambert Strether of Corrente.

Over the past, oh, decade or so Ive been so consumed with the battle to get everybody into the heatlh care
system Everybody in, nobody out, as Quentin Young puts it that I havent put much energy into
thinking about the heatlh care itself. After all, just because a house is energy inefficient doesnt mean that its
OK to leave people out in the cold. Now that single payer is no longer never, ever, but a program that could
actually be achieved with (an enormous) level of effort, KHNs new series, Treatment Overkill, which starts
with Liz Szabos So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients Ills,
provides me with a change to broaden my scope a bit, with a survey post like this one.

So Im going to look at two issues: (1) Is overtreatment a real problem? and (2) What are the causes of
overtreatment? Spoilers: Yes, and its complicated.

Confession time: Im the sort of person who doesnt get the idea of deductibles at all; I cant understand why
anyone would seek out medical treatment unless they were absolutely sure they needed it. And the reason I fear
the health care system is, in fact, the prospect (painful) overtreatment; the dental clinic that was going to give
me full anesthesia to remove a wisdom tooth; or my nightmare of end of life care hooked up to a machine in a
nursing home in a room with a television I cant turn off.

Overtreatment Is Real Problem

Evidence for overtreatment [1] falls into two categories: Anecdotes, and studies and surveys. Ill look at
anecdotes first.

Anecdotes isnt really a fair word, though; most of the stories are more about entire vertical markets (for
example, stents, as we shall see). Szabo starts out with this example:

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her
medical team, agreeing to harsh treatments in the hope of curing her disease.

In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six
weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she
had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 six years before her
diagnosis showed that a condensed, three-week radiation course works just as well as the longer
regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines,
endorsed the shorter course.

In 2013, the society went further and specifically told doctors not to begin radiation on women like
Dennison who was over 50, with a small cancer that hadnt spread without considering the shorter
therapy.
 Its disturbing to think that I might have been overtreated, Dennison said. I would like to make sure
that other women and men know this is an option.

(Note, sadly, that Dennison immediately puts the onus on the consumer patient to be informed; an obvious tax
on time, to be paid with the patient has the least time or energy to spare, instead of looking for the systemic
solution she vaguely hints at with would like to make sure. This impulse is a topic for another post.)

Nobel Prize Winner Bernard Lowns gives a second example in this interview (after demolishing bed rest for
heart attack patients as a form of medieval torture as well):

[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Womens Hospital in Boston] in
1960, I was asked to see a patient who was in her late 70s, demented, and had burns over 60 percent of
her body. She had been smoking in bed. They asked me to consult about putting in a pacemaker, which
she did not need. Furthermore, she was clearly dying, and implanting a pacemaker would only have
increased her suffering without prolonging her life. I was mortified. I wrote a note urging against a
pacemaker. It created quite a rumpus. If that were an isolated episode, it would be tragic. But that kind
of thing happened daily.

Here is a third, and egregious example, from Health Beat:

Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star
cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr.
Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who
didnt need them. A hard worker, he managed to knock off those 585 procedures in just two years, from
2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.

The Baltimore Sun broke Dr. Mideis story in January. In February the U.S. Senate Committee on
Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee
released a 1200-page report..

The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured
the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of
the companys cardiac stents into trusting patients in a single day: Two days later, an Abbott sales
representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a
barbecue dinner at Dr. Mideis home. Employees from St. Josephs attended the feast.

(It may seem that Im stacking the deck on causality here, but Im really not, although it would be foolish to
deny that such cases exist.)

Note again that these examples all involve treatment: Radiation treatment, a pacemaker, and stents. Were not
talking about ordering a few too many tests. (The American Family Physican supplies numerous classes of
overtreatment, not just anecdotes. See Table I.) Now to the studies and surveys.

Overtreatment in the United States, by Heather Lyu, et al (from the Public Library of Science, and thus peer-
reviewed) has induced a good deal of discusson since its publication in September 2017. From the Findings:

The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall
medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1%
of procedures.
Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot of stress and fear
induced for no reason. And if one out of every ten treatments is unnecessary, thats rather a lot of people going
to Pain City because their number came up, and not for any medical reason. Those odds arent quite as bad as
Russian roulette, but theye in the ballpark! I havent (yet) been able to find figures on the costs of
overtreatment, but there have been studies done on the costs of unnecessary care. Health Affairs:

Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of total health
care spending. Even the lower estimate, from the Institute of Medicine, amounts to nearly $300 billion a
year. No specialty is immune from practices that lead to overuse, as a recent spate of papers in medical
journals can attest. In cardiology, even using criteria that are relatively permissive, an estimated 11
percent of stents are delivered to inappropriate patients. At some hospitals, that rate is closer to 20
percent.

(Note that the figure of 11% unnecessary stents jibes well with Lyus figure of 11.1% of all procedures being
unnecessary.)

Im sure none of this is new to any medical professionals in the NC readership, but it was new to me, and may
well be new to NC readers especially those who received treatments that they retrospectively, or just now,
understood to be unnecessary.

The Causes of Overtreatment

Its clear that one cause for overtreatment is the profit motive. (I would speculate that individuals like Midei, the
stent dude, are edge cases, and that the real causes are more subtle and systemic.) Quoting again from Lyu, et al.:

The top three cited reasons for overtreatment were fear of malpractice (84.7%), patient
pressure/request (59.0%), and difficulty accessing prior medical records (38.2%) Seventy-one
percent of respondents believed that physicians are more likely to perform unnecessary procedures when
they profit from them. The interpolated median response for the percentage of physicians who perform
unnecessary procedures with a profit motive was 16.7%; 28.1% of respondents believed that at least 30
45% of physicians do so (Fig 2). Respondents who were attending physicians with at least 10 years of
experience (OR 1.89 (1.432.50) vs trainees) and specialists (OR 1.29 (1.061.57)) were more likely to
believe that physicians perform unnecessary procedures when they profit from them Respondents
compensation method and hospital characteristics were not associated with differences in perceptions on
the profit motive associated with unnecessary care.

So, the more experienced the doctor is, the more likely the doctor is to believe that profit drives unnecessary
procedures. However, the profit motive imputed to individuals cannot be the sole driver (see DICE:
Nonclinical Causes of Overtreatment for a model that includes Economics without being reductive) as this
letter in the British Medical Journal shows:

As a person who follows the evolution of health care policy from the vantage point of the United States,
I found BMJs May 12 article on Choosing Wisely in the UK [see here; CW is an informed consumer
model] very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a
culture of more is better fostered by such factors as defensive medicine, patient pressures,
commercial conflicts of interest, payment by activity, and the demands of pay for performance.

Many critics of the American health care scene ascribe the problem of irrational overtreatment
unsupported by available evidence in the U.S. to precisely the same causes, and argue that the key to
rationalizing American medical practice lies in adoption of the UKs single payer, universal coverage
health care system and the UKs system of civil justice. The fact that a Choosing Wisely program is
necessary in the UK, and for most of the same underlying reasons as apply in the U.S., proves that the
 UK has not found the panacea to achieving rational medical practice and that emulation of the UK
methods of health insurance, physician payment, and civil justice will not work as a panacea in the U.S.
either.

So, sadly, single payer as such is unlikely to solve overtreatment (although I cant think of an advocate who
ever said it would).

Conclusion

If there were one kind of doctor-patient relationship that I would like to see incentivized when single payer
comes to pass, its this one. Again Dr. Lown:

U.S. News: Problems with Americas health care system are economic, but they are also human. Whats
been lost in modern medicine?

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I
think that you cannot heal the health care system without restoring the art of listening and of compassion.
You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be
cultured in order to understand where the patient lives, why he lives like that, and also realize that the
leading cause of disease in the world is poverty.

Call me Polyanna, but I think if the health care system started treating patients like human beings, that a good
deal of overtreatment would be avoided.

NOTES

[1] Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves actual procedures
performed on a patient, often surgically. In other words, lots of pain and suffering imposed to no good purpose.
(Szabos article considers all three, but I am focusing only on overtreatment.) American Family Physicians
defines overtreatment as follows: Treatment initiated when there is little or no reliable evidence of a clinically
meaningful net benefit, where net benefit equals benefit minus harm.
74 comments
1. taunger October 24, 2017 at 1:41 pm

I worked as a disability advocate for years, which is a high volume practice. I read literally tens of
thousands of medical records during that time. I can say, unequivocally, overtreatment is an issue.

Causes are far more difficult to deal with. The high cost of medical care is a reflection of the low quality
of life many USAians are living. Listening is a good start, but far from the answer. Getting everyone in
the system, so that more preventative medicine can work, avoiding patient demanded surgeries with
low-probabilities of success would help as well. But even these two are just the tip of the iceberg.

In disability, chronic physical ailments mix with unemployment to form a deep pool of depressed
individuals. Even with access to great healthcare (which few have), the advice to exercise, stretch, and
eat healthy that would improve many conditions (spinal stenosis, other arthritis and orthopedic issues,
obesity, heart disease) is worth very little. In a depressed state, changing long term habits into healthy
ones is very difficult, and the prevalence of patients seeing a professional to make behavioral
adjustments in concert with their disease treatment is few, not counting those that show up to the
psychiatrist for medication regularly.

This is why single payer, jobs guarantee, and redistribution tax policy are necessary together.

Reply

1. Anon October 24, 2017 at 2:28 pm

Excellent comment. The last sentence is a comprehensive statement of actions needed to heal us
(U.S.)

Certainly, some will not respond to these actions, but many will and the attempt is magnanimous
for a consciously sick nation.

Reply

2. Lambert Strether October 25, 2017 at 3:22 am

> In a depressed state

I suppose an alternative, and more, er, final solution is opioids. Very profitable!

> single payer, jobs guarantee, and redistribution tax policy are necessary together.

I agree on the first two, but lets remember that the Federal Government, as the currency issuer,
does not require taxes to fund itself. Now, we should tax redistributively to: (1) prevent or
destroy an aristocracy of inherited wealth, (2) prevent the 1% from buying the state and civil
society with their loose cash, and (3) protect the children of the wealthy from grave
psychological and moral harm, but we dont need to tax them for program funding.

Reply

1. Carla October 25, 2017 at 7:41 am

 Thank you for this excellent post, Lambert, and for this clarifying comment. I would add
one more item to your list of reasons for a redistributive tax system: democracy itself
does not depend on a perfect equality of circumstances among the population, but it does
require a level of fairness and equal treatment that is simply impossible given the huge
disparity between Americans of low and average income and the squillionaires.

Reply

2. taunger October 25, 2017 at 1:31 pm

Lambert, exactly why I advocate redistribute tax policy rather than mere progressive
tax policy. The former is explicit in its intent, the latter falls more into the taxes fund
expenditures model, which any good NC reader knows is bullfeathers.

Reply

2. Arizona Slim October 24, 2017 at 2:03 pm

Experienced this a couple of years ago.

After a car wreck, both of my parents were hospitalized for a week. During that time, I got a lot of phone
calls from the hospital, and many of them related to getting my permission for this, that, and the other
test on my mother. Dad had Alzheimers, and, lucky for him, he evaded the endless tests. I guess the
doctors figured that he wasnt going to live much longer, so what was the point? (He died nine months
later.)

One of the phone calls really stood out. Mom was anemic, and the doctors wanted to do a colonoscopy
to find out why. Malnutrition! I said. Loudly.

This had been a problem for years. Mom and Dad simply werent eating enough. Ill get back to that
point in a minute. But let me say that I refused the colonoscopy for my mother. In addition to being very
invasive, I thought it was unnecessary.

Anyway, Mom got sent home and Dad was discharged to a nursing home. Once he was separated from
my mother, he started eating like a horse. Gained 15 pounds in less than three months. Then he started
losing weight and the nursing home sent him to hospice. In his case, that was the correct call.

Lets just say that my mother still has issues with food. Not a new problem. I remember it from my
childhood. But she does have caregivers who insist on proper nutrition. And she complies.

Last time I spoke with Moms doctor, he didnt say anything about anemia. Sounds like thats no longer
a problem.

Reply

3. Rojo October 24, 2017 at 2:04 pm

I think specialists are more likely to zero in on the problem the heart or lung or throat, while GPs
are more likely to treat the whole person.

But GPs are often referral gateways to specialists.

 Reply

1. Anon October 24, 2017 at 2:47 pm

General Practice doctors are hugely important in the healthcare system. They are the traffic cops
that direct patients to the appropriate specialist. They do most of the listening.

Reply

2. Nilavar, M. D. October 24, 2017 at 4:58 pm

I think specialists are more likely to zero in on the problem

Call me skeptic after being a practioner of Medicine over 40 years! I was a GP before got trained
as Diagnostic Radiologist after nearly 5 years of residency. I also worked as ER Physician in
early years. I am also licensed to practice in Ontario(Canada) but practiced only in USA after the
residency training!
A Diagnostic Radiologist is called a doctors doctor since the myriad of imaging exists to help
the clinical diagnosis. I came across virtually all kind of specialists, medical and surgical kind!
Ifound out to whom I wouldnt even send my dog for treatment!

There are ethical and morally conscious docs, but they are in the minority!VERY FEW!

A specialist is like a HAMMER, s/he sees everything as if it is just problem of NAIL! Surgeon
thinks through SCALPEL. Go to Pulmonologist, more likely you get bronchoscoped (needed or
not), Gastroenterologist gastro or colonoscopy, so on!

So buyer beware!

S.Nilavar. M.D.

Reply

1. Lambert Strether October 25, 2017 at 3:24 am

> buyer beware

Or beware being a buyer.

Reply

4. Anonymous October 24, 2017 at 2:07 pm

Imagine going to a restaurant where the waiter got to order for you.

You want the steak? OK better start off with these two appetizers I think youll like.
Youll need some wine too. Theres a 1994 Cabernet that will pair great with this. Ill mark
that down. The cost? Oh dont worry about that, your dining insurance will cover it.
Now for dessert. Theyre all so good, I have picked out three for you. You dont need
to finish them. Now Ill just add in my customary 25% tip (I am highly trained) and well
call it a meal.
 Reply

1. Lambert Strether October 25, 2017 at 3:27 am

The thing is, a trained, truly professional waiter can make all the difference to your meal. Its
their job to know the food and make your dining experience excellent, unobstrusively. (None of
this Hi, Im ______ and Ill be your server tonight nonsense). That was at least the theory in
France when I was there (sometime ago; it may have changed) and still is in the better
restaurants in Quebec. Being a waiter is being a waiter; its not a part-time job for actors hoping
for their big break.

It comes down to trust. We seem to think thats no longer important; not on the checklist. I think
its important, and I bet there are studies that prove the good effects of trust are measurable.

Reply

1. Carla October 25, 2017 at 7:46 am

Yes, trust. Essential to enjoying a great restaurant meal, successful medical treatment,
and a functioning democracy.

Reply

5. Vikas Saini October 24, 2017 at 2:34 pm

As a regular lurker here, its great to see you on this beat Lambert. Weve been on this for awhile now at
the Lown Institute. I refer you and the rest of the commentariat to a series we did in the Lancet which is
here:

The Drivers paper is pertinent as a description of the ecosystem of bad care.

FYI its a deep problem of modern medicine, part of the reductionism of the Flexner paradigm that
needs to change. Over treatment exists in Canada and the UK as well as in an utterly profit driven
system like the US.
Single Payer will be necessary but not sufficient for this problem. Monopsony will only go so far
without a revolutionary shift in culture and consciousness.

Reply

1. cojo October 24, 2017 at 8:29 pm

I had the pleasure of meeting Shannon Brownlee (I see she is involved in the Lown Institute)
during a month long public health fellowship during my last year of residency about nine years
ago. Her book Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, was a
pivotal tome that covered many of the issues, especially due to the Fee For service model of
medicine practiced in the United States. This came out in 2007, unfortunately it appears the
legislators drafting the Affordable Care Act did not seem to pay any attention, as controlling
costs and hence volume was not a significant focus of the legislation.

Reply
 2. Lambert Strether October 25, 2017 at 3:30 am

> Single Payer will be necessary but not sufficient for this problem.

That was my takeaway, too. My thought was single payer was necessary because the only way to
get leverage over the problem was to put it in the small-democratic arena. I could be wrong, but I
dont see a better alternative. The market will just go on chopping us into smaller and smaller
pieces.

Reply

6. oh October 24, 2017 at 2:50 pm

If the patient is the one who controls the payment, things may improve. Right now with insurance, there
is no one to one relationship between the patient and the health provider. Insurance companies stand
between the patient and payment. Even in the case of single payer, if the patient is given incentives to
get second opinions and refuse unnecessary treatment, things may work better.

Reply

1. Lyle October 24, 2017 at 9:38 pm

Single payer is likley to require second and if need be third opinions for non emergency surgery.
Most insurance pays for a second opinion if you want one (and would be a fool not to get) and if
need be a third opinion if the first and second dont agree.

Reply

7. kb October 24, 2017 at 3:03 pm

Kip Sullivan unequivocally disputes the overtreatment memeTo the contrary, we are under treated
in the US..
Please read:
The Health Care Mess: How we got into it and how well get out of it by Kip Sullivan..

Reply

1. Tooearly October 25, 2017 at 2:18 am

And Kip is about as smart a person writing about our health care scene as anyone I know.
I tend to agree that we dont get nearly enough good (think primary) care but n my experience
we also get lots of wasted care. I for example have seen ERs repeat CAT scans on a patient more
often than weekly for the same condition a practice that should be malpractice but instead is
highly profitable.
There are many drivers for such waste and of course single payer is not a panacea for them nor is
it meant to be one.
It seems hard to imagine that we might one day make The practice of medicine something that is
not entirely commodified the way it is today but indeed that is what needs to happen if we were
to change this.

Reply
 2. Lambert Strether October 25, 2017 at 3:31 am

I think we can be undertreated as a polity, and yet overtreated for those who manage to make it
through the obstacles to secure care. Too many anecdotes on overtreatment for it not to exist, and
the incentives are so obvious

Reply

8. hreikd October 24, 2017 at 3:08 pm

Over treatment: My moms story. From several years ago.

So I was the guardian for my very (VERY) demented mom whom we kept at home, at great cost but
also great benefit to her. She had a basal cell tumor on her forehead. About the size of a nickel. She was
90 at the time. I live in one state, she the next state over about 2 hours away. She had full time help at
home.

So one of my innumerable trips to help out and oversee, involved taking her to her md appointment at
Brigham and Womens. She had a wonderful gerontologist, who referred me to a dermatologist
affiliated with B &W. Her care giver took her a few weeks later and I got a call from the dermatologist,
a young woman. Now Im an old woman but a trained m.d. in Internal Medicine. I also knew (by then )
a great deal about dementia. And especially dementia in my particular mother.

So when the dermatologist called me she said your mom needs a MOHS procedure. Well, a Mohs
procedure is an 8 hour stop and go procedure. They keep cutting until the margins are clean. They cut,
send the specimen to the lab, wait for the result and cut again. Patient is awake the whole time so theres
no anesthesia risk, but 8 hours on a table for a woman with advanced Alzheimers was not going to work.
I told the dermatologist that theres no way my mom could tolerate that. The dermatologist got irate.
Tried to scare me by saying, the tumor could grow into her brain!. I said, moms 90, shell be dead
b/f the tumor goes anywhere!

They were so intent on this procedure and challenged my right to speak on moms behalf. so.. I had
to fax PROOF of my guardianship for them to let me have the last say. I was pretty discharged. And
complained bitterly to the referring doc when we saw him next. and he mentioned that my complaint
wasnt the first.

Then I found out that the MOHS surgeons get a ton of money at the places they work, like $700,000.00 /
year.

Reply

1. Nemo October 24, 2017 at 3:57 pm

Thank you for sharing. It helps to know I am not alone in such experiences.

I often wonder how epidemic stories like yours are. I feel like I could write a whole book based
on personal experiences along with those of family and friends. A person really has to educate
oneself just to avoid being robbed blind or worse yet harmed, and you at least have the fortune of
a medical education. To have to education oneself (trying to filter all the misleading marketing
information and quacks out there) on complex medical procedures on top of everything else is
exasperating beyond words.
 How long do we, and those we care about, have to continue suffering the indignities and
malfeasance of a broken and corrupt (not worth using euphemisms to debate the issues at this
point anymore) healthcare system?

Reply

1. Carla October 25, 2017 at 8:07 am

As long as corporations have constitutional rights and can buy the government, which
they can do because money = speech: http://www.movetoamend.org

Reply

2. nilavar, MD October 24, 2017 at 9:28 pm

Why am I NOT surprised?

As I have written on many forum, over the years, this was pointed in early 90s by extensive
research at RAND Corp and ar Fraser Institute (Canada) that up to 2/3rd of
tests/imaging/surgeries have NO clear medical indications and NOT needed. This is also
confirmed in my practice over 40 years, in various scenarios ( private,university practice).

It is so sad to observe that it is still going on! Just demonstrates the power of the vested interests
in the medical industrial complex.

Reply

1. Lambert Strether October 25, 2017 at 3:34 am

The topic of this post is overtreatment, not overtesting. I can live with some excess
overhead from testing. But I cant live with being cut open for no good reason other than
systemic incentives, often financial.

Reply

1. cojo October 25, 2017 at 7:06 am

Unfortunately over testing goes hand in hand with over treatment. There is a thing
called an incidentaloma that our radiologist friend Im sure can attest to. These
are findings on diagnostic testing that do not answer the question at hand, but
cannot be ignored, leading to more testing, usually of the more invasive type
including being cut open. This is where physicians must have a grasp of Bayesian
analysis, pretest and post test probabilities, etc. to not only know when to order a
test, but also when NOT to order a test.

Reply

9. McWoot October 24, 2017 at 3:52 pm

Id be surprised if a significant contributor to the overtreatment pie wasnt Pharma advertising

 Reply

10. clarky90 October 24, 2017 at 4:17 pm

The underlying premise of modern medicine is flawed. It dumber than Medieval bloodletting.

Allopathic medicine is brilliant for catastrophic events. In the case of paraplegic injuries, over the last 50
years, their survival rate, in the first two years after the injury, has increased dramatically. However their
long term life expectancy is about the same as it was 50 years ago.

Trends in Life Expectancy After Spinal Cord Injury

Results
Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the
critical first 2 years after injury. However, the decline in mortality over time in the post2-year
period is small and not statistically significant.

http://www.sciencedirect.com/science/article/pii/S0003999306004060

We are bamboozled by the complexity of the modern medicine model, BUT, it is stupidly simple.
They define a normal range of numbers. This range is arbitrary and always changing. What is normal
cholesterol? PSA? Blood sugar? ferritin? vitamin D?

Then they subject the patient to an array of blood tests, x rays, scans, urine tests

Then, the allopatic doctors use drugs or surgery in order to get your test numbers in the normal range.

Before you know it, the patient is on 15 drugs. They cannot sleep so they are prescribed sleeping pills.
Then they are depressed, so anti-psychotics- Finally Oxycontin for the constant unbearable pain.

Allopathic care in NZ is cheap, readily available, but a death trap for the trusting (except for catastrophic
events). USAians pays hundreds of thousands of dollars for misery and drug induced ill-health.

If cat poop (feces) were cheap and available in one place (NZ), but outrageously expensive and rationed
in another (USA), it is still, basically, just cat shite.

Reply

11. VietnamVet October 24, 2017 at 4:40 pm

The problem is for profit healthcare. The more tests and treatments, the higher the managers bonuses.
There is no regulation except for the insurance companies who are only interested in their own bottom
line. The patient is not in a position to rationally oversee their care by themselves. All that matters today
is profits; no matter how they are achieved. That is why American life expectancy is decreasing. Besides
giving everyone healthcare; a system of primary physicians, government oversight of hospitals and care
facilities plus jail time for criminals are also needed.

Reply

12. kareninca October 24, 2017 at 4:43 pm

 I have relatives by marriage who live in southern Indiana near the Kentucky border. They are
respectable working class, and I guess they must have good health insurance. I have never known
anyone to have so many surgeries. It is astounding. Cardiac surgeries and orthopedic surgeries, for the
most part. The ones I have in mind are 58 and 62 years old; they have never smoked; they go to Mass
every Sunday, they have been happily married since they were young and while they dont eat health
food they dont eat every meal at McDonalds. But it is surgery after surgery after surgery. They never
question the doctors; they never hesitate. And now, unfortunately, some consequences of the surgeries
are coming due; the guy is in the hospital with infections both in his pacemaker and in his heart valve
(they just replaced both; hell probably be okay). No-one else I know has surgeries like this. I think it is
a regional scam. Its true that my dad in CT has had a number of vascular surgeries, but he smoked for
decades and the dire need for them has been very apparent.

Here in northern CA, I have a friend whose girlfriends son went to the emergency room a number of
years ago for a bad finger cut. He was told he needed amputation. Then they found out he had no
insurance. He was told to use a salve, and in fact it worked fine. I also have a friend here in Silicon
Valley who recently had digestive problems. The MRIs, CAT scans, lab tests and probings under
sedation were endless. Finally she was told to stop eating acidic food.

Reply

13. nihil obstet October 24, 2017 at 4:54 pm

Reducing the profit motive as much as possible is why I would prefer a National Health Service (call it
VA for all). Insurance, even if its single payer, is still open to fraud and overtreatment. Lets try to think
of medical practitioners as professionals rather than entrepreneurs, and get them to think of themselves
that way. I also see it as a possible way to reduce the very high premium given to specialists, so that
more would go into primary care.

Reply

1. Nilavar, M. D. October 24, 2017 at 5:09 pm

In modern Medical practice, PROCEDURALISTS ( Surgeons of all kind, Cardiologists,

orthopods, Pulmonologists, gastro enterologists anfd of course, invasive and diagnostic
Radiologists etc ) always get compensated more than the primary care providers!

There are more CPT codes to charge for specialists than the GPs or FPs

Medicine is business run by 3rd parties! Vested interests wont allow any challenges to status
quo, just the banking system and the FIRE Economy!

Reply

1. Lambert Strether October 25, 2017 at 3:36 am

> There are more CPT codes to charge for specialists than the GPs or FPs

See here and here at NC on medical coding.

Reply
 1. nilavar.MD October 25, 2017 at 5:39 pm

NOTHING, I am NOT aware of, during my practice!

There used to be under 5000, now apparently after the EHR & EMR, there are
over 13-16K codes to choose!

Reply

14. Wade Riddick October 24, 2017 at 4:59 pm

With all due respect, if the UK system has embraced, commercial conflicts of interest, payment by
activity, and the demands of pay for performance then that means they have a substantial set of profit
incentives already in place, rendering their medical system *more*, not *less*, similar to Americas.
They may have single payer but that just captures the monopoly rents by regulating the
cartel/monopoly/utility or whatever you want to call the medical establisment (its per se difficult to
even talk about market competition when theres only one drug or treatment that will save a patient).

The unregulated private provision of public goods like medical care always leads to extortion for profit.
If you privatize fire-fighting, entire cities will burn to the ground. If you privatize schools, you get
ignorance. If you privatize prisons, you get kidnapping-for-profit and the highest incarceration rate in
the civilized world.

If you privatize the military, you get endless war. Why would a for-profit business ever win a war? For
that matter, why would they ever lose? The wars over and theyd be out of money. You think its just a
coincidence that in the age of corporate personhood (Citizens United) and unlimited bribery of public
officials, youve had two of the longest, most expensive and least determinative conflicts in our history
in Iraq and Afghanistan?

You think its a coincidence that the more unregulated markets we through at medicine, the more
expensive our medical care becomes and the sicker we all get?

Cures dont make money. Repeat customers do.

Show me a for-profit business thats in business to go out of business and Ill show you the perfect
company for insuring against social hazards.

Its simple middle-manager fraud. Politicians love privatizing government because they get to pocket the
public budget. When the marines or public school principals hand tax dollars back to politicians and
their cronies, everybody goes to prison. Privatize it and then you can have the contractor or charter
school give you campaign donations no doubt celebrating your economic genius in the process.
They can hire your spouse and cousins. The contractor can even bid up the real estate and then rent it
back to themselves at exorbitant prices. There are a million ways to launder the money.

Why do you think there is no transparent public accounting on most of this stuff? The budget disappears
into a black hole which, incidentally, youll discover the minute youre in a hospital, dealing with a
pharmacy benefit manager (PBM) or health insurer. That was the true purpose of MERS to make good
mortgage information disappear so CDO purchasers would never know what was in the mystery meat.

This is the great unraveling of Progressive Era controls on public corruption.

If you pay a dotor for every surgical screw he installs, is it any surprise then that a diabetic winds up
getting several in his spine he never needed?

This is also how we have set up the aluminum and copper markets, letting speculators buy and horde
commodities to drive up the price. Its also how we run drug distribution under the PBMs. PBMs
provide a kickback in the form of a stocking fee to pharmacies which would get people sent to prison
in other industries. When derivatives traders are not end consumers or producers of a commodity, they
bid up prices the same way. We actually give pharmacies a profit incentive to drive cheap, effective,
public domain chemicals off the market in favor of expensive, privately patented medicines. Because
they are expensive, they pay a greater kickback so the pharmacy has greater incentives to stock and push
it.

When railroads charged both farmers and consumers shipping and receiving food, it bankrupted both
sides of the transaction by creating incentives to reduce supply in the monopoly transportation network.
Reducing rail capacity bid up transportation prices and saved the company on investment. Thats how
you raise profits: raise prices, lower expenses. They had no rival to compete. Thats why these
kickbacks were outlawed. Imagine if the post office made you buy a stamp for every letter you receive.
Oh, wait. We have that with the end of net neutrality. The ISPs get paid both by the service supplier (e.g.,
Netflix) and by their customer (you and I).

You this same rationing take place now with drugs. Since legalizing PBM kickbacks, drug prices have
soared and weve lived through some of the greatest drug shortages since the Soviet Union went
bankrupt. Hundreds of chemotherapy patients per year have died because cartels control supply and they
dont like patients getting cheap, efective, public domain treatments. Go look at the availability of
methotrexate over the last ten years or your platinum-based compounds. No one tells you this. Its a blip
on the back page of a newspaper (and pretty soon we wont even have those). Do you think TV news
making its profits off drug ads will ever talk about this?

Its a new war of enclosure and its far more extensive than simply drug markets. The privatizers are
confiscating clean air, potable water, healthy food, public education, public policing and a host of other
general welfare functions of the government promised us in the preamble. It all traces back to the
ideology of for-profit government which, in technical political science terms, is called fascism when
businesses own and operate the government for private gain.

By the way, we dont need less testing in medicine. We need more. I dont know a single idiot in Silicon
Valley who ever said we need less data collection. The simple fact is we need to test everything in a
patient and compare everything we collect across thousands of diseases. The cost of sensors and DNA
sequencing, imaging and protein detection not to mention data processing has been falling
dramatically and yet reformers always stress rationing as the cure for health care prices. Its partly
because we ration preventative medicine and diagnostics that were in this situation.

Another great place to start would be separating diagnostics (evaluation) and treatment. Would you let
the banks chief loan officer also serve as the chief auditor? Yet we let the same doctor diagnose, treat
and evaluate his own work.

As someone with serious chronic illness from these frauds, listen to me when I tell you we should be
practicing medicine thousands of patients at a time with transparent public auditing and big data model
building. Building my own private model of genetics from public research saved my life. Nobody does
that for you in medicine. Nobody is paid anywhere in the system based on whether you get the cheapest,
most effective and safest treatment; in fact, Ive heard of people getting fired for exactly that.

Reply
1. nilavar, MD October 24, 2017 at 5:37 pm

By the way, we dont need less testing in medicine. We need more.

ah?

No test is 100% accurate! Every test has a potential for a FALSE positive or FALSE negative
result.

False + may lead to unnecessary more testing and probably unneeded surgery! False negative
gives false sense of relief!

Every test has to stand alone for specificity, sensitivity and accuracy, by statistics!

Reply

1. Wade Riddick October 24, 2017 at 7:48 pm

Youve answered your own question. No single measurement, in isolation, is 100%

accurate. Thats why we need thousands.

We need a cheap gene array chip that measures 10,000 markers in the blood and we need
a big data project to match those measurements against a baseline. We need cheap, safe
whole body scans. We need measurements of what every cell is up to and how they
deviate from the norm.

Nobodys very angry that cell phone cameras keep getting better, yet somehow were
always upset that doctors want plenty of tests. That camera is a sensor that measures our
environment and the chip gets better and cheaper each year. We need the same attitude in
medicine. But then cardiologists might get upset that an immuno-assay shows youre at
risk for atherosclerosis. These guys still dont want to accept that clogged arteries are an
immune system problem and the immune specialists dont want to accept that it mostly
gets started in the gut. And the gut guys dont want to have anything to do with
immunology or cardiology.

Round and round we go

Reply

1. nilavar October 24, 2017 at 8:51 pm

The future is human genomes for diagnosis and tailoring treatments on individual
basis. But that day is yet to come!

Reply

2. Lambert Strether October 25, 2017 at 3:38 am

> should be practicing medicine thousands of patients at a time with transparent public auditing
and big data model building
 As long as financial incentives dont distort the data (and more importantly, which data is
collected). Eh?

Reply

1. nilavar.MD October 25, 2017 at 5:48 pm

Does any one in HEALTHCARE system including all kinds of physicians, Hospital
Administrators, Insurance executives, health policy pundits or whomever, know:

How much each procedure (of any kind!) or treatment, COSTS ( the REAL-exact,
occurred cost) to the provider or the health institution before it is charged (before padding
up their profits %) to 3rd party payers or the patient themselves?

There were a few articles in NYT where the hospital CHARGES for Cholecystectomy
(gall bladder) varied from $3000 to $10,000 at different zip codes. But none listed the
REAL cost occurred!

NONE of them have come forward to reveal that secret, if any b/c it gets charged as
long as the market bear it!

Cost (?!) over run will added to next years premium!

An enigma in Medicine practiced as business, unlike other!

Reply

15. Oregoncharles October 24, 2017 at 5:09 pm

Ill have to read the post this evening, but I have something to add to the theme:

I was in a meeting where a prominent local single-payer advocate, an emergency room doctor, told us,
passionately, that administrative costs were only half the problem,. or less. Overtreatment and
overtesting were the bigger part. He blamed the doctors, but of course their billing practices are a big
factor.

A big advantage of single-payer is that it creates an institution with the power and motive to change
medical practice. Iatrogenic illness is a big factor; overtreatment can kill.

Reply

16. Mayo One October 24, 2017 at 5:13 pm

My wife has some chronic health issues and is a regular visitor atand occasional guest of the Mayo
Clinic, traditionally seen as the home of integrated medicine (i.e. the various specialties speak with
each other). We count ourselves ridiculously, ridiculously fortunate to be able to so often and easily rely
on the oft-named best hospital system in the world. That said, its amazing to both of us, even there, how
silo-ed medicine has become. This silo-ing HAS to create an inordinate amount of overtreatment. The
generalists, however, are left far behind in the community practices, often not able to do much beyond
prescribing antibiotics and making referrals. There is a LOT of need for more holistic thinking about the
patient that modern western medicine has lost, likely inadvertently, as greater knowledge leads to the
 need for greater specialization. The gap of some type of master generalist (which would of course be
another layer of expense in the healthcare system) is filled either by the patient (of patients family) or
left void. As a result, theres either a huge tax of time, stress, frustration spent searching internet chat
boards and medical reference sites to understand topics because it seems like no single doctor gets it,
or a hugely inefficient and potentially quite harmful medical treatment experience as each specialty
chips away at their corner of the patient. Im not sure what the answer is, but if this is the experience of a
frequent Mayo Clinic patient, Id wager that the question posed is a pretty fundamental one to the entire
practice of modern medicine.

Reply

1. nilavar, MD October 24, 2017 at 9:10 pm

Master Generalist!

You are absolutely right. The primary care provider has to be the THAT coordinator of
numerous consultants/specialists (diagnosis & treatments) looking at the (piecemeal) patient
through their tunnel vision of their respective (organ) specialties but giving less attention to the
big picture the patient as a human being and his or her interest as a top priority.

But currently that is huge responsibility for the primary care provider involving a lot of
UNCOMPENSATED (time &money) care, very few can afford. It is a gap yet to be filled in our
healthcare system!

For my family, friends and relatives, I have been that master generalist for many years. I have
been both GP and also specialist in my life time. There has to be a STRONG patient advocate
either a family member or a close friend to look after the true interest of that individual. Without
that person, a patient is at the risk of under, over or no (neglect) treatment in our healthcare
system.

Reply

17. PlutoniumKun October 24, 2017 at 5:21 pm

I would add an extra over to your list overdiagnosis.

One of the the few bright spots in published stats for the US compared to other countries is an apparent
higher survival rate from cancers. I mentioned this to a relative who is a medical specialist and he just
laughed. its not surprising he said since an amazing number of those treated in the US for cancer dont
actually have cancer. Quite simply, overuse of dubious tests results in a huge number of false
positives for cancer. This leads to successful treatments. There are many tests in the US which are
simply not permitted in countries with public systems because they produce far too many false positives
to justify their use, either because the cancer doesnt exist, or it is not sufficiently malignant to justify
treatment (apparently there are cancers that lie dormant without ever threatening life). Im not aware,
however, if this has ever been quantified, but its certainly true that there are many testing protocols
commonly used in the US which are actively recommended against in most European health systems as
they are considered not just a waste of money, but actively harmful.

A relative of mine who is a very highly regarded specialist in drug prescribing practice in Europe is
currently doing a one year study on practice in the US (focusing on opiates, as it happens). He said that
one of the initial findings is that there is a different culture around prescribing in the US to what he is
familiar with. Quite simply, US doctors are not taught how to say no to patients in a way which
doesnt upset them or feeling theyve been given a brush off.

Someone mentioned overuse of heart operations above. In Ireland, they developed what are called Sli
na Slainte walks, which have spread worldwide. These were developed by the Irish Heart Association
following complains that patients were asking for too many drugs and treatments, and not doing the
simple thing which was shown to help in the aftermath of heart attacks exercise. They are way marked
walks of set distance doctors simply prescribe the walk instead of drugs. They are hugely successful.
But there is no money in it, so guess where they havent been adopted?

*disclaimer* I should say Im not a medical professional, but I do have an interest in the topic.

Reply

1. nilavar, MD October 24, 2017 at 5:44 pm

US doctors are not taught how to say no to patients in a way which doesnt upset them or
feeling theyve been given a brush off.

But there is always another doctor willing to say YES! Shopping for yes doctors is NOT
usual! They are called DR. Feel good ;-)

Remember, Medicine is a business in America!

Reply

2. Chris October 24, 2017 at 5:44 pm

Thank you, PK. Very interesting, and follows from a thoughtful and insightful post from
Lambert, but I guess it makes common sense to strengthen heart muscle and accelerate the
bodys natural ability to heal itself through exercise. Pity about the commonness of common
sense though, but I digress.

We all know we can live longer and avoid or postpone chronic ailments by maintaining a healthy
weight and doing some exercise, particularly cardio. And our arms and legs may look the same
over our declining years, but if you dont use them, you will lose them, those muscles that is.

I post. that such an ideal is too far when you are time and money poor, constantly worried and
depressed

Poverty and sickness and lower mortality theyre all linked to one another. Designed and baked
into the dying system

Reply

3. JohnS October 25, 2017 at 12:35 pm

..walking is a curative/extender for people with heart disease.I am a prime example

 in 2000, at age 52 I had a collapsed lung and stopped smoking and started walking.in 2001 I
had a massive heart attack and a quad bypass, which I survived due to a year of walking 30 per
day.

in 2010, my lung collapsed again and I was diagnosed with Emhysema (no cure then or
now)..I asked the Pulmonoligist, How much can I walk, because if I dont walk, I will soon
die as my heart will weaken.
The Dr. said, No one has ever asked me that question.they all just go home and walk slow!

So, I used the oxygen tank with an extended line and swim noodles so I could swim and do
water exercisesthen I tried to stay on my feet for 3-4 hours per day (moving slowly) 6 days
a week..I increased both my heart size and my lung capacity due to this regimen

I also watch my diet.but, do eat the good/fun food in moderation, but avoid salt.

And, I avoid large gatherings during the cold and flu season because they could kill me
quickly..

17 years later, I am finally slowing down.BUT, I got all these extra years by JUST KEEPIN
ON MOVIN ON..

My Pulmunoligist said, You are unique and we really dont know what to do for you.just do
what youve done.you are an inspiration!

Reply

18. JBird October 24, 2017 at 6:54 pm

None or too little, or too much, and very occasionally just the right amount of medical care for the lucky
few. What a mess.

Ill add that the elderly, and the poors, opinions seem to be discounted by caretakers as if you are lucky
enough to be old or unlucky enough to be destitute means youre soft in the head. So if a patient can
understand and communicate what they want and realistically need they have to fight to be listened too.

Reply

19. Steve October 24, 2017 at 7:25 pm

Four years ago my father who was 78 at the time began having difficulty eating. He had been diagnosed
with parkinsons a couple years earlier but the meds he was on were acceptable and effective for him.
He was a brilliant physicist. Well they did a colonoscopy and found tiny tumors. One couldnt be taken
care of at the time and the process to his death began. No one knew how long the tumor had been there
or at what speed it would grow but chemo and radiation were prescribed to make it easier to remove.
This became a very long sad story which I will not go into detail on right now. The chemo made my Dad
horribly sick. The radiation to pin point a tiny area less than the size of a quarter ended damaging all his
organs. He died in pain on Thanksgiving morning 2 years ago. The radiation had done too much damage.
When he asked questions about treatment he was shuffled to diffident doctors or just not answered.
These were very high end NE Medical facilities. The reason he went in for digestive problems never
were fixed. Had the tumors never been addressed he could very well be alive today. To date I have over
 5 friends who have had a parent die not from the condition they sought help for but the radiation
treatment.

Reply

1. Lambert Strether October 25, 2017 at 3:41 am

> Had the tumors never been addressed he could very well be alive today

I understand that many prostate cancers are cancers you die with and not of.

Its almost like your body tissues are nothing but sites for rental extraction, if you fall into the
wrong hands, which is a Happyville vs. Pain City thing, entirely random.

Reply

1. nilavar.MD October 25, 2017 at 6:10 pm

Clinical and biological behavior of cancers, host response, response to

chemo/radiotherapy VARY from individual to other.

some cancers grow slowly and some faster than the others, Specific cytology/histology
matters.

Breast cancers in women -30s/40s are aggressive grow faster and metastasize. Same
cancer in late 70s or 80s grow very slowly.

There is NO single answer to all cancers and behavior and response to treatments! The
inherent individual-host immunity/response also matters!

Reply

20. mirjonray October 24, 2017 at 8:09 pm

For me the problems start with the routine physicals which are free courtesy of Obamacare. The
doctors run tests and find problems with this and that, and after ultrasounds and CT scans and little
surgeries to get rid of benign little thingies, before you know it youve spent thousands of dollars
(courtesy of high deductibles ) for basically nothing. This last time around my GP didnt like a few
things in my lab results and I ended up with a specialist. He started off with why are you here to see me
today? After questioning me for a little while about my (lack of) symptoms, I finally told him, I never
would have come here on my own if my doctor hadnt have sent me here.

Reply

21. allan October 24, 2017 at 8:49 pm

Genetic testing will increasingly be a cause of overtreatment:

Lawsuit: Woman had unnecessary mastectomy, hysterectomy based on mistaken diagnosis [Oregonian]
 A 36-year-old southern Oregon woman underwent a double mastectomy and a hysterectomy
based on genetic tests that medical professionals mistakenly said showed she carried cancer-
causing genes, she claims in a $1.8 million lawsuit.

Elisha Cooke-Moores lawsuit says that she had the radical, life-altering surgeries only after her
gynecologist, Dr. William Fitts, determined that genetic blood tests indicated she had a 50
percent chance of getting breast cancer and up to an 80 percent chance of getting uterine cancer.
The suit states her nurse practitioner, Lori Johns, also misread the test results and recommended
a mastectomy.

Cooke-Moores lawsuit says Fitts erroneously told her she had the MLH1 gene mutation and
Lynch syndrome which indicate an increased risk of colorectal, uterine, ovarian and other
cancers. But she later discovered after the surgeries that her test results indicated no such thing,
according to the suit and her attorney.

Reply

22. cojo October 24, 2017 at 9:04 pm

Dr. Lown is on to something:

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care
system. I think that you cannot heal the health care system without restoring the art of listening
and of compassion. You cannot ignore the patient as a human being. A doctor must be a good
listener. A doctor must be cultured in order to understand where the patient lives, why he lives
like that, and also realize that the leading cause of disease in the world is poverty.

Medicine is becoming more dehumanizing. This is not only structural due to shorter patient visits, less
face to face interaction, fewer family physicians treating the whole family, visiting the patient at their
home, to see what their environment/neighborhood is like. It is also the way physicians practice
medicine, treating patients as mere data sets. Im not trying to minimize data in medical decision
making, but taken out of context from the human element, treating data may be misleading and may not
be treating the patients ills.

In my experience, when I see a patient coming in over and over for the same complaints, it is likley due
to one of three main reasons. One, they are either being misdiagnosed and mistreated, two, they are
seeking a special test or drug, or three, their symptoms are not due to an organic medical cause, but due
to some sort of somatization secondary to life stressors. Trying to figure out which it is requires the
clinician to listen to the patient and understand where they are coming from. Unfortunately, when a
primary care physician only has 10 minutes per visit, it is much easier to order a battery of tests to not
miss any important diagnoses, or to just capitulate to patient demands than to listen, and in many cases
take the time to give the patient some much needed reassurance.

That being said, the patient is not always an innocent bystander in this. There are also many times that
the clinician will pick up on the dynamics mentioned above, but reassurance will not satisfy the patient.
The patient will demand more be done for a number of reasons. These are mostly anecdotal, such as I
read an article and think I need such and such a test, or my friend/family member had this procedure
done and I need it two. It sometimes takes me twice as long to explain to a patient why they dont need
something done as it does as to why they do. This is a societal thing and this is linked to the problem of
defensive medicine. I like to joke, that physicians always get sued for not ordering a test that may have
been indicated, but rarely if ever get sued for over treating someone and then causing harm. Perhaps it
 has something to do with the ethos that its better to do something and look like youre trying that to do
nothing, even though that may be the best course for the patient.

In the end, I think physicians need to be better trained to listen, remember the mantra of first do no
harm, and treat each patient as if they were their close family member. The incentive structure in
medicine has to also change, including the way physicians are reimbursed, as well as the way
information and clinical data is sourced and distributed to avoid excess industry bias. And finally,
patients have to understand that more is not necessarily better, they or their relative do not have a god
given right to every experimental, and outrageously expensive treatment available if it does not apply to
them clinically and if the chances of it prolonging life are minimal.

Reply

23. GERMO October 24, 2017 at 9:27 pm

Overtreatment cant possibly be as big a problem as undertreatment, at least certainly not in the world of
crappy insurance or subsidized careour experience was definitely a solid reluctance to order expensive
tests or to consider that the problem might be complicated and costly. Which it turned out to be, and the
eventual surgery was scheduled as late as possible, as a last resort, and we had to insist on more
thorough testing to get a proper diagnosis. They just wanted to save money. The tumor grew all the
while this organization was hoping it was something minor. I dont want to hear about overtreatment,
thanks it seems to always get distorted into blaming the patients for greedily consuming too much
healthcare!

Reply

24. John Yard October 24, 2017 at 10:29 pm

I had a minor open abscess on my back. Standard treatment is in-office minor surgery, with local
anesthesia. I was referred to the head if surgery of a major teaching hospital , who insisted on full OR
surgery under general anesthesia. He refused to consider in-office surgery. I refused the full OR overkill.
After about a year of argument with my healthcare provider , I was referred to a dermatalogical surgeon
for in office surgery. Took 5 minutes, with local anesthesia. Fixed the problem. But it took a year of
war to avoid unnecessary and expensive surgery.

Reply

1. Oregoncharles October 25, 2017 at 3:33 pm

Youve changed doctors, right?

Reply

25. Ming October 24, 2017 at 11:09 pm

Healthcare practices, much like bureaucracy, are generally pretty slow on the uptake of new advances.
There are little incentives for doctors to advance their practice or to really push for their patient interest,
despite the hollow chanting of evidence-based medicine advocates.
 When I asked why hypofractionated treatments (shorter course for the breast radiation therapy or
prostate) arent adapted for radiation treatments, some claimed ignorance while others blamed it on
insurance policies only qualify certain on treatment types, few oncologists are interested in pushing for it.

Granted, the price of 25x radiation treatments (5~6weeks) isnt very different from 20x or
16x(3~4weeks) radiation treatment for the hospital, since it is typically billed by the cancer types,
radiation treatment types. I doubt the oncologist received more incentive (by a significant margin) with
longer treatment scheme, although this definitely imposes an additional cost on the patient. Overall
though, I dont think differences in treatment duration are an indication of overtreatment itself.

On the other hand, I think the referral system is sometimes causing overtreatment. For example, a
prostate cancer patient that is referred through GP > Urologist > Oncologist pathway is far more likely
to undergo localized surgery before ADT and radiation therapy, even though, in some case, there is no
evidence that this is beneficial to the patient.

Sometimes picture the referral system almost look like a modern highwayman system, where everyone it
out for their cut.

background: medical physicist (allied health) experience working in Asian.

Reply

26. Joel October 25, 2017 at 1:45 am

Two common threads in these stories seem to be that 1) the overtreatment mostly happens to the elderly;
2) its mostly for expensive procedures, not routine ones.

In my teens, 20s and 30s I had a number of easily and inexpensively treated health problems that were
only diagnosed when I lived outside the US.

If you are a young person with a $2500 deductible you arent getting overtreated.

Reply

1. Lambert Strether October 25, 2017 at 3:44 am

Excellent points!

Reply

2. terry October 25, 2017 at 7:27 am

Yep true implications for uk too

Reply

3. nilavar.MD October 25, 2017 at 6:02 pm

In my teens, 20s and 30s

,
Were there:
 CT scans, MRI, Pet scans, ISOTOPE imaging, Ultrasound imaging, Echocardiography?
Percutaneous renal drainage?Percutaneous Angioplasty?

-Broncho-scopy , gastroscope, colonoscopy, Linear accelerator (instead of Cobalt machine) to

treat cancers?
advanced/new antibiotics and other medications?

Good OLD days, yep they are OLD for a reason!

Reply

27. Tooearly October 25, 2017 at 2:26 am

Highly recommend people read a new book out Why We Revolt by Victor Montori MD at the Mayo
Clinic. A compassionate clear headed and well written look at what ails modern medicine.

Reply

28. Lambert Strether October 25, 2017 at 3:45 am

Thanks to readers for the excellent comments on this thread. Adding, passionate facticity is a phrase
that just popped into my mind.

Reply

29. Paul P October 25, 2017 at 3:57 am

I was surprised to see psychiatric drug treatment go unmentioned

in examples of unnecessary treatment. Robert Whitaker made a convincing case in his book, Anatomy
of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in
America, that drug treatment has been shown to be ineffective compared to supportive, non-drug
treatments. Whitaker,
a journalist, convinces by citing studies of treatments done by psychiatrists.

Reply

1. cojo October 25, 2017 at 7:19 am

If you look at the top 5 prescribed medications by class, you will see, acid reflux medications,
hypertensives, cholesterol lowering, anti depressants and pain medications not necessarily in that
order. Theoretically, all but the pain medications (in short duration) can also be treated by
lifestyle modifications of diet, exercise, weight loss, and emotional health.

Reply

1. cojo October 25, 2017 at 7:24 am

for most people.

Reply
30. Bkrasting October 25, 2017 at 9:51 am

L Congress is trying to legislate overtreatment.

https://www.cbo.gov/publication/53241?utm_source=feedblitz&utm_medium=FeedBlitzEmail&utm_co
ntent=812526&utm_campaign=Express_2017-10-24_12%3a00

Reply

31. roxan October 25, 2017 at 2:53 pm

Ive seen both over treatment and under treatment, both as a nurse and personally, so maybe the problem
is Bad Treatment. There seems to be no consistency. Just now I am on the phone, trying to make an
appointment with a specialist I saw a few years back. They are not even able to change my address!

Reply

32. Oregoncharles October 25, 2017 at 3:41 pm

And a personal experience:

A couple of years ago, I experienced a frozen shoulder. In case you havent had this treat, it hurts like
unholy h..l, especially if you try to use the arm. And yes, it was the result of overstrain, my own poor
judgement.

Long story short: The specialist prescribed physical therapy, which I faithfully pursued, since Im on
Medicare. After a month or so, I realized that it was making the problem WORSE. My arms swelled up
all the way to my hands. That called for cortisone, and about that time my therapist ran out of patience.

The frozen shoulder went away after about a year, just as the therapist, in a moment of candor, had said
it would. Not perfect, but perfectly usable. As far as I can tell, the best treatment was none, maybe some
aspirin to get through the day. Hmmm could have been an opioid pretext; at least my doctors were
good enough not to try that. I hope I would have refused.

I wonder whether physical therapy for frozen shoulder is ALWAYS that harmful?

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33. nilavar, MD October 25, 2017 at 6:29 pm

My one word response EXACTLY: to cojo (october 25, at 6.25pm), way above gets deleted, repeatedly!

Is that offensive?

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1. Outis Philalithopoulos October 25, 2017 at 6:45 pm

A comment, offensive or not, will not necessarily get published if it doesnt add independent
content.
 When someone habitually uses caps lock or exclamation points, it is the equivalent of shouting in
the middle of a conversation its not the worst thing in the world, but it doesnt do much to
build a constructive atmosphere, either.

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34. D October 25, 2017 at 7:46 pm

Just want to say that I appreciate all of your above commentary, Dr. Nilavar, its important to have
actual Doctors weighing in on such an important subject.

As a cancer patient for quite some time now, I have had to push back on both over testing and over
treatment by a world renowned hospital run by Money Men.

Capitalizing the word exactly in many instances, is more appropriate than not, to many of us being
abused in Hospitals with utterly no recourse.

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