ny times: The Power of 'No' ( as it pertains to health care)

[amborin]

In Medicine, the Power of No

How can we learn to say no?
The federal government is now starting to build the institutions that will try to reduce the soaring growth of health care costs. There will be a group to compare the effectiveness of different treatments, a so-called Medicare innovation center and a Medicare oversight board that can set payment rates.
But all these groups will face the same basic problem. Deep down, Americans tend to believe that more care is better care. We recoil from efforts to restrict care.
Managed care became loathed in the 1990s. The recent recommendation to reduce breast cancer screening set off a firestorm. On a personal level, anyone who has made a decision about his or her own care knows the nagging worry that comes from not choosing the most aggressive treatment.

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From an economic perspective, health reform will fail if we can’t sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare’s long-term budget deficit will grow.
So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. “Being able to say no,” Dr. Alan Garber of Stanford says, “is the heart of the issue.”

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It’s not just CT scans. Caesarean births have become more common, with little benefit to babies and significant burden to mothers. Men who would never have died from prostate cancer have been treated for it and left incontinent or impotent. Cardiac stenting and bypasses, with all their side effects, have become popular partly because people believe they reduce heart attacks.

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Can we solve the entire problem of rising health costs by getting rid of needless care? Probably not. But the money involved is not trivial, and it’s the obvious place to start.
Learning to say no more often will be a three-step process, and if the new agencies created by the health act are run well, they can help with all three.
The first is learning more about when treatments work and when they don’t. “All too often,” the Institute of Medicine reports, the data is “incomplete or unavailable.” As a result, more than half of treatments lack clear evidence of effectiveness, the institute found. It says the most promising areas for research include prostate cancer, inflammatory diseases, back pain, hyperactivity, and CT scans vs. M.R.I.’s for cancer diagnosis.
As part of the health act, a Patient Centered Health Research group will have an annual budget of $600 million. Relative to total health spending, that’s a paltry sum. But it’s real money relative to what’s now being spent on such research.
The second step — and maybe the most underappreciated one — is to give patients the available facts about treatments. Amazingly, this often does not happen. “People are pretty woefully undereducated about fateful medical decisions,” says Dr. Michael Barry of the Massachusetts General Hospital, an advocate for sharing more with patients.

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.....They decide the risk of incontinence and impotence isn’t worth the marginal chance of preventing prostate cancer. Or they choose cardiac drugs and lifestyle changes over stenting. Or they opt to skip the prenatal test to determine if their baby has Down syndrome. Or, in the toughest situation of all, they decide to leave an intensive care unit and enter a hospice.

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The final step is the bluntest. It involves changing the economics of medicine, to reward better care rather than simply more care. Health reform doesn’t go nearly far enough on this score, but it is a start.
The tax subsidies for health insurance will shrink, which should help people realize medical care is not free. And doctors who provide good, less expensive care won’t be financially punished as often as they now are.

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http://www.nytimes.com/2010/04/07/business/economy/07leonhardt.html


eta: "the tax subsidies will shrink"

this is one of the nightmare scenarios that hcr critics have predicted: a bronze plan is not great coverage; the co-pays and premiums are steep; when subsidies shrink, who will even have minimal coverage?

[Mimosa]

1. The authors analysis and conclusion is WRONG

I think most people do NOT choose 'overtreatment'.

And I know that we who are underinsured often say 'no' to going in and having moles checked, or getting tests for all kinds of symptoms, or going to a urologist to check what's going on with frequent urination, because we cannot afford the co-pays and we know we could not afford the deductibles if something did require treatment.

Screw the jerk, David Leonhart http://topics.nytimes.com/top/reference/timestopics/people/l/david_leonhardt/index.html?inline=nyt-per, who wrote that opinion piece. It's not factual. What does he know about what patients go through?

BTW, has anybody here ever met a doctor who actually KNEW THE PRICE of what she or he was prescribing? Have you ever met a doctor who knew the cost of a lab test? I haven't. And I've known a lot of doctors. I've had to tell them why i couldn't afford tests and medicines even though I'm insured.