Beware Mission Creep

by | Feb 26, 2018 | Health Care Costs, Medical Tests, Pharmaceuticals, The Practice of Medicine | 1 comment

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Recently I had the great pleasure of giving a talk to a group of University students who are part of Mannkal Scholars. These are students who are wanting to expand their minds and be challenged by ideas rather than retreat into safe spaces.

The topic was the Black Hole of Health and financial issues confronting health systems worldwide. Countries have differing systems, but the issues of aging populations and increasing chronic as against acute illness is worldwide.

One driver of increased expense is that of “too much medicine” – procedures and tests that are done with little benefit. In the last week or so it has emerged that up to one in four knee and hip replacements in Australia may be un-necessary and that up to $700 million each year was being spent on procedures being done in hospital that could be done at doctors’ rooms.

This is a serious issue for two main reasons. Firstly, all medical procedures carry risk. It can be minimised but never eliminated. The key is that the potential benefits outweigh the risks. If there is little or no likely benefit to doing a procedure then the risks cannot be justified.

Secondly there is a cost involved to the system. In health systems with finite amounts of money, whatever is spent on a needless procedure is not spent on one that is needed. Time is also finite as are operating room slots. An unnecessary procedure blocks space for a needed one.

In the USA the National Academy of medicine estimated wasteful treatments and tests cost US$765 billion per year or 25% of the total spend. Needless procedures can have complications and tests can lead to patient stress and more procedures to prove there was never a problem in the first place.

This is driven by three factors. A fear of litigation, patient demand and financial incentives to doctors with no cost to patients as it is covered by insurance. A surgeon gets paid more to operate than not to. Ordering tests immediately sets up a follow up consultation for results.

This is also important as the concept of a “simple “blood test has gained traction. The process is simple but the consequences may not be.

Another factor in this, which I have highlighted before, is the lowering of thresholds when we classify someone as having high blood pressure of high cholesterol, to name but two. When cut offs are lowered a large number of people get reclassified from not having a problem to having one and needing “treatment”.

As with surgery, all medications have side effects. These also must be subjected to a risk benefit assessment. Where there is little or no benefit (in terms of quantity or quality of life) then side effects cannot be justified. In addition there is cost to the individual and the health system using dollars that could be better spent elsewhere.

The system is geared to provide more medicine. When the question is asked as to how much healthier we are for it, the answer is not clear. Studies on heart stents (in stable heart disease) and arthroscopic surgery have shown no benefit compared to non-operative approaches. And of course, there is the over prescription of cholesterol drugs.

Modern medicine has made advances. Modern tests and procedures can be of enormous benefit. But too much of a good thing is also a problem We need to beware medical mission creep.