In our blog postings, other publications and presentations, we have frequently
addressed the problems associated with the overuse of medical procedures,
readily available studies, and radiology exams. While in some cases this
menu of diagnostics is warranted, there are hundreds of cases where more
care is not better treatment, and, in fact, can often make outcomes far worse.
Recently, my physician son said he thought in 10 years a hospital admission
would be seen as a failure of excellent health care. He may be right.
And yet, we read and hear stories about CEOs building more beds and putting
in place strategies to fill them so that they can say their institution
is practicing “good medicine”. They are doing this while inpatient
volumes are falling between 5% and 10% in most hospital across the country.
I think we all would have to agree that any illness is not good medicine,
and the “good medicine” the CEOs are referring to is “good
finances” driven by higher revenues.
In addition, there are many health care delivery scenarios that support
the hypothesis that no illness is good, and that a focus on prevention
of these illnesses would do much to improve the health of millions. Three
of the most obvious are smoking, obesity, and excessive drug and alcohol use.
Although we have known for years that smoking leads to disorders ranging
from mild shortness of breath to virulent emphysema and lung cancer, we
continue to provide misaligned incentives that do not inspire true change,
as most reimbursement is still provided for the treatment of the diseases
rather than for the elimination of the cause. If smoking cessation materials
and counselors were reimbursed at even 10% of what cancer care costs,
I am sure there would be significantly less smokers in the world. And
if the patient was incentivized to stop smoking, by having a reduction
in their health care premium, or even getting a financial reward for each
year they continue to be smoke free, we would see an even greater reduction.
Patient engagement in positive prevention activities must replace their
asking for more pills and medical interventions as their health continues
We are also familiar with the myriad illnesses that are caused or exacerbated
by obesity, the number one health malady in the world. A study by the
Trust for America’s Health and the Robert Wood Johnson Foundation
reported that in 31 states, more than one in four adults are obese, But
rather than seriously encouraging both the patient and provider to focus
on weight reduction through aligned incentives, we continue to reimburse
more and more for medicines and therapies to treat the resultant pedal
edema, congestive heart failure, and uncontrollable diabetes. Fortunately,
we are beginning to hear positive outcomes for many obese patients who
undergo bariatric procedures, which are still not covered by a majority
of insurance companies. We are supporting, once again, a chronic disease
over a preventable disease.
A final example is trauma, now the leading cause of death in people 65
years and older. Sadly, death from trauma is projected to go higher in
the next decade.
Although gun injuries are leading the growing number of trauma cases, auto
accidents caused by people under the influence of alcohol and drugs remain
a major contributor. Will this increase with the legalization of marijuana
in some states? Trauma care is the most complex and expensive to provide,
and is often poorly reimbursed. So again, would supporting programs focusing
on prevention of the causes be money well spent?
Based on just these three scenarios, it seems clear that for some illnesses
and injuries we are applying more and more of our resources on treatment
plans which have no long-term benefit and will obviously not improve quality
of care while lowering costs. To be successful, health care transformational
strategies must align incentives, expenditures, and reimbursements that
support our premise that “less” at times is better than more!