This blog cross-posted at Kevin MD

A few months ago I was introduced to a gentleman who had been a corporate VP for employee benefits at a Fortune 100 company for many years.  I was impressed with his knowledge of health care.  He shared some of his experiences with company employees, who lived all over the country.

The company had a policy that when employees were informed they had a very serious medical condition, the company paid for a second opinion.  For example, when employees were told they needed a heart transplant, the company paid the cost for travel and a second opinion at the Mayo Clinic.  Mayo found that 40% of the transplants that had been recommended to employees were not medically necessary or appropriate.

The VP saw cases in which transplants were recommended for people who were going to die soon from cancer whether the transplant was done or not.

Sometimes hospitals and surgeons were extremely aggressive in promoting transplants that could not possibly be beneficial to the patients.  One hospital recommended a heart-lung transplant for a patient.  When the patient visited Mayo for a second opinion, it was discovered that neither a heart nor a lung transplant was indicated for the patient.  She left the hospital with no surgery.

Another employee was told he needed a heart transplant.  When the VP called the surgeon at a well-known institution to tell him that his company will pay for a Mayo second opinion, the surgeon said the patient shouldn’t fly on a plane in his condition.  In fact, the employee has just traveled on a plane to see the surgeon and was happy to go to Mayo for a second opinion. The second opinion revealed a small blockage that was successfully managed with a stent.

The VP said the team in his company that worked with Mayo had a wall of cards and notes from grateful employees.  The employees who were spared massive surgeries called the VP’s team members and thanked them over and over again.  The employees cried, the team cried, and so did the VP.

I’ve been working on overtreatment for a long time and have written about it in The Treatment Trap but this took my breath away.  The opportunity cost is profound when it comes to transplants.  Medically unnecessary transplants take life away from those who could die without a new heart.

So far, the work to shine a light on overtreatment is compelling and includes:

• the “Top Five” list of good practices in primary care that lead to appropriate care, no more and no less, developed by the National Physicians Alliance, funded by the ABIM Foundation, and published in the Archives of Internal Medicine
• the ABIM Foundation’s Choosing Wisely campaign whose message is that wise choices are integral to medical professionalism

We need to get to the high hanging fruit where real and immediate harm is occurring.   As for the former benefits VP, his approach has been to take patients away from the overtreaters.   I think Hippocrates would agree this is the right thing to do.

This blog cross-posted at Consumer Reports

It used to be that to undergo lap-band surgery, in which an inflatable silicon band is wrapped around the stomach to make it smaller and control the urge to eat, you had to be seriously obese. That meant having a body mass index (BMI) of 40 or higher, or a BMI of 35 or higher plus a serious weight-related health problem, such as diabetes. But the Food and Drug Administration recently relaxed those rules: People with BMI of 30 plus a weight-related health issue are now candidates.

The company that makes the band, Allergan, has video testimonials on its website from people who say they’ve had the surgery and tout its benefits.It even a held a contest to give away a free surgery to three "lucky" winners.

Blogs advertise the surgery as if it were a luxury vacation—“All inclusive.  We’ll beat or meet any advertised price! Only $3,999!”

But don’t rush to jump on the bandwagon. A closer look at the fine print reveals troubling risks. The firm’s own website reports a study that followed 299 people for three years after the  surgery. Twenty-five percent of them had a second operation to remove the band.  

That’s a lot of dissatisfied customers. Imagine if 25 percent of people who owned Toyotas were so dissatisfied that they called up their dealers and asked them to come and take their cars out of their driveways.

That’s not all. Nine percent needed a second operation to fix problems with the band.  Nine percent needed an additional procedure to fix a leaking or twisted access port, a design issue that the manufacturer says has been improved. Four people had the band erode into their stomachs.

Less serious side effects are also common. Half the people who had the procedure reported nausea and vomiting. Thirty-four percent suffered from gastroesophageal reflux, 24 percent of people experienced band slippage (which might stem from excessive vomiting), and  14 percent developed stomach blockages.

For some people, lap-band and other related weight-loss procedures can be appropriate. But surgery—particularly one with known risks—should never be taken lightly. So before you consider it, make sure you’ve exhausted other proven ways to lose weight. And make sure you and your doctor have a thorough discussion about the potential risks of the surgery, and make sure that it’s right for you. 

This blog cross-posted at Consumer Reports

Have you had an X-ray or CT-scan lately? The number of such scans has multiplied in recent years to some 70 million. And nearly a third of CT scans done in adults and a quarter of those in children are like to be inappropriate, according to a 2007 article in the New England Journal of Medicine. All that exposure translates into substantial risks. Researchers at theNational Cancer Institute have estimated that 29,000 cancers could stem from CT scans performed in 2007, particularly of the abdomen, chest, head, and pelvis.

To help correct the problem, the Radiological Society of North America recently called for a new plan to limit and track radiation exposure from imaging tests. Until that system is in place, here are few things you can do:

1. Learn about the risks. Go to RadiologyInfo.org for details about radiation doses from common imaging tests.

2. Ask about alternatives. Before you undergo any imaging test involving X-rays, ask if it’s really necessary or if there are any alternatives. And make sure your doctor knows about other tests you have had, so you can both determine whether the risk of the additional exposure is worthwhile.



3. Avoid duplicate tests. Make sure that medical records travel with you to different departments and facilities, so that tests aren’t unnecessarily repeated.

This blog cross-posted at Health Affairs

The costs of the medical liability system have received attention in Health Affairs recently, and the dialogue presents an opportunity for foundations to make a difference in the medical liability system in a new way. Best practices are emerging that offer a patient-centered approach to reduce medical malpractice lawsuits while also improving patient safety.

The ethics of medicine require health care providers to tell patients about adverse events that cause harm, yet these conversations occur infrequently. The University of Michigan Health System (UMHS) was one of the first health care organizations to establish and implement a policy and practice of informing patients and families when preventable harm occurs.

The principles underlying the UMHS policy are patient-centered. When harm occurs through unreasonable care, the organization must make it right. When the care that staff members provides is reasonable under the circumstances, they need to be supported even when something goes wrong. A commitment to learning from medical errors helps the organization continually improve its quality.

With funding from the Blue Cross Blue Shield of Michigan Foundation, UMHS reported its experience in the Annals of Internal Medicine. The study documents a decline in the average monthly rate of lawsuits from 2.13 to 0.75 per 100,000 patient encounters and a commensurate reduction in legal costs and patient compensation costs. While the study design does not establish causality between the disclosure practices and a reduction in lawsuits or costs, similar approaches adopted in other health care organizations suggest that transparency in the aftermath of medical harm results in multiple benefits.

The University of Illinois Medical Center at Chicago (UIC) has adopted a comprehensive, patient-centered system to respond to adverse events. UIC staff meet with the patient, apologize, and provide a remedy, whether patients want to file a claim or not. They waive fees for hospital and physician services and prescription drugs. The hospital puts a hold on bills that would otherwise be mailed to the patient’s home.

In the first two years, the policy of open and honest communication resulted in more than 4,000 incident reports annually, prompted more than 200 investigations to analyze the cause of the incidents, and led to nearly 200 system improvements. Nearly 300 conversations have taken place with patients and families, and fifty more in-depth disclosures occurred where inappropriate or unreasonable care caused harm to patients. A substantial decline in lawsuits and associated legal costs occurred, according to physician Timothy McDonald, UIC’s chief safety and risk officer.

Patient safety and medical malpractice are intertwined. The Agency for Health Care Research and Quality (AHRQ) has made this important link in its work on patient safety and medical malpractice liability. Foundations can support the establishment and growth of comprehensive systems of patient-centered disclosure in hospitals. Grant funding would be well spent to support the study and publication of research on well-developed systems of disclosure and their impact on patient safety and on liability costs. Grantmakers can multitask and strive to improve patient safety and reduce medical liability costs simultaneously.

A patient-centered approach to dealing with the aftermath of adverse events is good for patients, good for health care providers, and good for reducing health care costs.

This blog cross-posted at Disruptive Women in Health Care

With all the hand wringing about health care costs, it is possible to cut costs without harming patients. Even better, costs can be reduced while making patients better off. Here’s how.

An unspoken truth is that three kinds of medical treatment are provided in the U.S. The first is treatment whose benefit is unquestionable. Surgery to treat a ruptured appendix is an example. Without it, death from life-threatening infection is almost certain. The life-saving medical care being rendered to earthquake victims in Haiti is in this category.

A second type of treatment is provided when uncertainty exists about benefits and risks. Doctors and their patients must balance the benefits and risks. The recent mammogram controversy fits into this gray zone.

The third type of treatment is when the possibility of harm exceeds the possible benefit. A panel convened by the Institute of Medicine years ago called it “overuse”. This is the subject of my new book, The Treatment Trap.

Health care tests and treatments today are like the colors of a traffic light. Life-saving treatments flash green. Where uncertainty exists, the light flashes yellow. With overuse, the light flashes red and tells us to stop.

We don’t stop at red lights in health care. In fact, we run right through them. In a survey conducted by the American College of Physician Executives, eighty percent of physicians who responded said they were very concerned or moderately concerned about their physician colleagues overtreating patients to boost their income. Fifty-four percent said they were concerned about their peers admitting patients to a hospital to increase their bottom line. The survey respondents are in leadership positions in hospitals, medical practices and other health care organizations.

Overuse is the third rail of modern American health care. The medical establishment and politicians don’t want to touch it. One person’s overuse is another person’s payment for college tuition or a mortgage on a McMansion.

Here’s why we should touch the third rail. Overuse is not just about money. Ask Ron Spurgeon, a California millwright who had bypass surgery for non-existent heart disease along with hundreds of other people who had needless cardiac procedures at a California hospital. Ron survived. Not everyone does.

According to a Commonwealth Fund survey, about one-third of Americans say that have had tests or treatment they thought was unnecessary. A lot of people are falling into the treatment trap, it seems.

In the health care reform debates, a new commission was proposed along with a commitment to test options to reform the “do more get more” payment system. Why wait for a commission or payment reform to curb overuse? Right now we can begin eliminating tests and treatment that yield no benefit. Let’s start with Pap tests performed on the ten million women who are not at risk for cervical cancer because they have had a total hysterectomy and no longer have a cervix. Yes, it’s true.

Even better, we can stop paying for surgeries that expose people to great risk and confer no benefit. When the Rand Corporation and the Harvard School of Public Health asked expert doctors to provide a second opinion on coronary angiograms, which show whether the heart’s blood vessels are blocked, the doctors found that one-third of people who were recommended for heart bypass surgery did not need it. This is what happened to Ron Spurgeon. It is one of many examples of surgeries, tests and procedures that are overdone.

Democrats and Republicans are concerned about ballooning budget deficits. It is hard to think of a more sensible public policy than to stop spending money on medical treatments and tests that cause more harm than good. It’s time to stop running red lights. It’s never good for your health.