My wife's leukemia was diagnosed when she went to the hospital with chest pains. Standard procedures included basic blood tests and those found the blasts. As my wife had acute leukemia (ALL) she basically had 4 months to be diagnosed and that SOP test saved her life.
The balance, then, is to not only re-evaluate what is being done, but also to retain standards - even if the accountants don't understand the need.
And there is also a need to evaluate the long term benefits of increasing testing. The A1c test is great for identifying diabetes, but isn't used that much compared to its potential use.
I would like to see a "high volume, negotiated" price where the government can significantly increase A1c testing, even at the school levels. Obesity has been moving towards a level that makes it a major national problem, especially when future costs of treating diabetic problems is considered. Now is the time to stop those problems.
There is an epidemic driving up the costs of health care.
What Atul Gawande identified during the health care debate as an excess of testing by doctors who own clinics and testing gear results in enormous regional differences on diagnosis, according to a study published last month in the New England Journal of Medicine.
What’s most remarkable in the study done by Dartmouth on millions of Medicare records is that more diagnoses does not mean better outcomes. But the impact of over-diagnosis lasts a lifetime. Once you’re a cancer patient, you’re always going to be a cancer patient.
Another result is an overdose on treatment for ills that may not be threatening. As Gilbert Welch of Dartmouth noted, “Exactly what are we doing to our children when 40?% of summer campers are on one or more chronic prescription medications?”
The good news here is that the Dartmouth study was made possible by the mass use of health IT, through Medicare. Enormous amounts of data now exist that can be sifted to detect patterns we could not find before, and track those patterns to their bottom line as in this case.
But none of that means anything unless we are willing to take the next step, prescribing the behavior of doctors or proscribing unnecessary treatment.
Doctors who are over-diagnosing patients don’t believe they are doing anything wrong. Even if they’re shown that they are not improving outcomes, they may be reluctant to change their behavior.
They will get enormous political support on this, not just through their industry but ideological support. Any system that denies a test, a diagnosis, or a treatment to a patient, even based on clear trends in the data, will be descried as a “death panel’ and “getting between the patient and their doctor.”
But someone must. Some process must be established to turn the results health IT is getting into meaningful best practices that doctors can be made to follow, with payments questioned or withheld when they are not.
At the end of that road lies a health system that costs less, as a percentage of our national income, than the current system, but which delivers care from a public fund — and insurance is a public fund — only when it is necessary.
And between here and there health IT is going to face many political headwinds. They will start with the confirmation fight over Dr. Donald Berwick (above) as head of the Centers for Medicare and Medicaid Services. A hearing on that nomination has yet to be scheduled.
The Administration denies it, but at the end of the day health reform demands rational rationing of services, rather than the irrational rationing of checkbook size we use now. Care should be given when care is necessary, based on data, not on the whims or financial interests of the person providing the care.
That’s the fight being joined in the Berwick nomination. Berwick’s Institute for Healthcare Management has proven you can have better care, even universal care, by paying attention to procedures, and by doing the right thing routinely.
But many doctors don’t want to be told what the right thing is, believing their degrees give them the power to make those decisions themselves. They do. But not with the public’s money.
Medicare and Medicaid, the government-funded health systems for the aged and the poor, are where this battle on behalf of data and procedures will start. By denying those agencies Dr. Berwick’s expertise, opponents of the Administration hope to maintain the present system.
The one that gave us this epidemic of diagnosis in the first place.
