As breast cancer patients know, over-testing and over-treatment are big woes

choosing-wisely@2x-300x197Up to a third of medical spending goes for over-treatment and over-testing, with an estimated $200 billion in the U.S. expended on medical services with little benefit to patients. But getting doctors and hospitals to stop this waste isn’t easy, nor is it a snap to get patients to understand what this problem’s all about so they’ll push their health care providers to do something about it.

Which is why kudos  go to Julie Rovner, of the nonprofit, independent Kaiser Health News Service, and National Public Radio for the recent story on how older women with breast cancer suffer needlessly and run up wasteful medical costs due to over-testing and over-treatment.

Rovner and Kaiser Health News worked with a medical benefit management company to analyze records of almost 4,500, age 50-plus women who received care for early-stage breast cancer in 2017. She found that just under half of them got a medically appropriate, condensed, three-week regimen of radiation therapy. Research has shown this care is just as effective as a version that’s twice as long, costs much more, and subjects patients to greater inconvenience, especially with more side-effects.

Why don’t doctors get with the times, embrace a shorter, less costly treatment with less detriment to their patients and that has been written up favorably in the New England Journal of Medicine six years ago, and has been endorsed by the American Society for Radiation Oncology?

With roughly 250,000 women diagnosed annually with invasive breast cancer, it’s more than a $64,000 question about varieties in care. Studies show that women who undergo the longer radiation regimen, as opposed to those who get the short version, face $2,900 more in medical costs a year after their diagnosis. Now, multiply that sum by thousands or even tens of thousands of women for whom radiation treatment might be indicated and who ought to at least get an informed choice about shorter vs. longer regimens.

Just going back and forth to a hospital for treatment itself can be an ordeal for women living in rural or exurban areas, Meg Reeves, 60, told Rovner. Once Reeves underwent radiation treatment in rural Wisconsin, her doctors then told her she needed resultant, repeated check-ups, MRIs, and blood tests. The care, which she now thinks may have been excessive, left Reeves feeling as if she had been “treated with a sledgehammer.”

In my practice, I see not only the harms that patients suffer while seeking medical services but also the injury that they can be subjected to by defensive and excessive over-testing and over-treatment. Patients struggle too much already to afford needed medical services much less those that are wasteful and unnecessary.

The ABIM Foundation, created by the American Board of Internal Medicine and dedicated to the improvement of the practice of medicine, and Consumer Reports five years ago launched a great initiative called “Choosing Wisely.” The two organizations worked closely with an array of colleagues and medical specialists, as well as medical educators, to raise awareness about and to campaign against unnecessary, wasteful, and potentially patient-harming over-treatment and over-testing.

As the trade publication Modern Healthcare has reported, “Nearly 80 medical societies are now part of the campaign and 500 recommendations on ways to curb overuse of healthcare services have been issued. Many health systems have also implemented Choosing Wisely principles at their organizations.”

To their credit, the leaders of Choosing Wisely also have subjected their work to independent study to see how and if their efforts are working and to discover ways to improve it. Alas, the medical establishment has been slow to take up the reforms recommended by their peers and prestigious practitioners.

Dr. Eve Kerr, an evaluator of the overall Choosing Wisely campaign and a professor in the department of internal medicine at the University of Michigan, told Modern Healthcare that: “What we’ve learned is that it’s just really hard to change practice. Medical professionals have been practicing one way for a long time and patients expect that kind of practice … [To make changes] that doesn’t happen in five years.”

It may be that reformers need to be more direct and urgent in their recommendations. They may need to twist arms harder at hospitals and in medical schools and teaching hospitals. They also may need to step into the mine field of how providers get paid—challenging the current and pervasive practice of doctors and hospitals profiting by getting fees for each service rather than an alternative, such as bundled payments (in which, say, hospitals and doctors set a price for a given procedure, then the hospital gets one payment and splits it among all involved).

It also may be that patients will get angry enough about sky-high medical costs, and they will insist ever more about the need for doctors and hospitals to respect their fundamental right of informed consent—that is they will force MDs, for example, to explain slowly, carefully, accurately, and fully what might happen to them in various medical treatments and to be frank, clear, and independent about their potential risks and benefits. It’s not too much to ask, considering that the consequences not only can be life and death but also financially destabilizing for patients and families: Consider that some patients may spend as much as $475,000 for a single dose of some cancer drugs, without all the required, other services included (such as hospitalization).

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