Curbing unnecessary care in a value-based care setting
The National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program has been tracking cancer deaths and cancer diagnoses since 1973. For each of the 30 types of cancer it tracks, there’s a table showing the diagnosis and deaths over time. Diagnosis of many of those cancers—including thyroid, kidney and melanoma—have skyrocketed, yet deaths have remained relatively unchanged. Glancing at those tables, you might be tempted to think that modern medicine has won the war on cancer and that treatment has advanced so much that it’s preventing deaths. But a growing consensus among healthcare providers suggests another problematic conclusion: overdiagnosis.
As screening and diagnostic technology advances to the point where clinicians can detect the smallest of abnormalities, patients are being overtreated for conditions “that are not destined to ever bother them.” That’s how H. Gilbert Welch, M.D., defines overdiagnosis in his 2011 book, Overdiagnosed: Making People Sick in the Pursuit of Health.
“Since doctors don’t know who is overdiagnosed and who is not, overdiagnosed patients tend to get treated,” he writes. “But an overdiagnosed patient cannot benefit from treatment. There’s nothing to be fixed—he will neither develop symptoms nor die from his condition—so the treatment is unneeded. An overdiagnosed patient can only be harmed. And the simple truth is that almost all treatments have the potential to do some harm.”
In the book, he points to prostate cancer screening that measures the prostate-specific antigen (PSA) serum levels as one of the most egregious examples of cancer screening with good intentions but bad results. “The fastest way to get prostate cancer is to be screened for it,” Welch writes.
The U.S. Preventive Services Task Force, which issues recommendations for screening and diagnostic testing based on relative benefit and harm recommends against PSA-based screening for prostate cancer. It concluded in its 2012 final recommendation that PSA-based screening leads to substantial overdiagnosis and overtreatment of prostate tumors which, had they been undetected, would have never progressed to the point of harm.
“Even for men whose screen-detected cancer would otherwise have been later identified without screening, most experience the same outcome and are, therefore, subjected to the harms of treatment for a much longer period of time,” according to the task force.
Is That Stent Necessary?
Interventional cardiologist Gaurav Aggarwala, M.D., at Magnolia Health Systems in Palestine, Texas, is well aware that overdiagnosis (and the corresponding treatment with angioplasty) is a problem for patients with stable cardiac disease. By some estimates, about a third of all stents placed annually are unnecessary.
That’s why before any stent is placed, Aggarwala always measures the fractional flow reserve (FFR) of the artery blockage. It’s an extra step, but one that gives him confidence and objective data on which to base his clinical decision. “If the FFR is abnormal, we feel comfortable that the patient got a stent for the right reason,” he says.
Aggarwala indicates angiograms can carry a high level of observer variability—he might see an 80 percent blockage where another cardiologist might see a 50 percent blockage. That’s why it’s important to have “a modality that people can’t argue with,” he says. FFR is one way; another is an intravascular ultrasound, which can also help measure the severity of blockage.
He started requiring the practice after reading about government investigators, including the Centers for Medicare & Medicaid Services, cracking down on inappropriate stenting. “I started thinking about how I could protect myself if my practice was ever scrutinized,” he says.
Government investigators are interested in unnecessary stenting from both cost and patient safety perspectives. About 1 to 2 percent of angioplasty patients will experience procedural risks, such as blood clots, bleeding or a tear in the artery. On top of that, most patients who undergo the procedure are prescribed blood thinners for at least 12 months after the stent is placed, which carries additional risks.
“The fact is if you don’t need a stent, you shouldn’t get one,” Aggarwala says.
The Challenge of Patient Expectations
But no treatment or a wait-and-see approach can be a hard pill to swallow for patients seeking a quick fix. And, they might seek a second opinion until they can find a provider who will do more than prescribe lifestyle changes.
Michael Schlosser, M.D., FAANS, was a neurosurgeon before he became the chief medical officer for HealthTrust. On a daily basis, his practice saw overdiagnosed patients who were seeking a second opinion for back pain. He says many of them would come in having already gotten an MRI that showed a dark disc.
“Because of that dark disc, they were previously given the diagnosis of degenerative disc disease, which set up a psychology that they felt like something had to be fixed,” he says. “But most of the time we found it was just normal mechanical back pain, which does not require surgery. But since the incorrect diagnosis was already there, it was harder to address the behavioral changes that actually could help their pain.”
Both Schlosser and Aggarwala admit that patient expectation is a huge challenge to curbing overdiagnosis and subsequent overtreatment. Practicing evidence-based medicine, however, can enable a patient’s willingness to engage in a provider’s treatment decision.
“You can’t just say, ‘We’re not ordering an MRI scan,’ ” Schlosser says. “You have to be able to say, ‘Given your symptoms and your general state of health, here’s what the evidence tells us is appropriate.’ ”
As more healthcare organizations become subject to reimbursement based on patient outcomes, overdiagnosis and overtreatment increasingly become important problems to solve because they’re such a big source of additional costs. The Dartmouth Institute for Health Policy and Clinical Practice, the New England Healthcare Institute, McKinsey and Thomson Reuters have estimated that about 30 percent of all Medicare spending (which totaled $597 billion in 2014) is for unnecessary care that has no positive impact on health outcomes.
“As providers become more at risk, whether through capitated care models or other value-based care scenarios, they must be savvy about what good care looks like in order to avoid overdiagnosis,” Schlosser says.
It’s not just the cost of the first test that detects a non-harmful abnormality; it’s also about all the subsequent treatment decisions made as a result of the initial diagnosis.
“There’s a long-term effect of making the right decision now,” Aggarwala says. “If a patient gets a stent, there’s the cost of the procedure and the risk of complications, but there’s also the multiple follow-up visits and the cost of continual healthcare associated with the treatment of a stent. Every time he has chest pain, you’re going to be more aggressive in subsequent diagnoses and treatment because of it. It’s a cumulative add-on effect for the rest of that patient’s life.”