What If The Problem Is Too Much Care?

August 19, 2009|By Phil Manger

One day a little less than two years ago, I received a phone call from the hospital. Doctors wanted to perform a needle biopsy on a mass in my mother's lung. The mass had been discovered during a CT scan they had ordered to try to locate the arterial blockage that was causing the transient ischemic attack (TIA), or mini-stroke, that had sent her to the hospital.

I drove down to the hospital and, without thinking much about it, signed an authorization for the procedure. I then went to see my mother and explained what the doctors wanted to do. She became very upset.

On my drive home I started thinking about all this. My mother was 88. She had emphysema and was on three liters of oxygen around the clock. She suffered from rheumatoid arthritis and macular degeneration and was legally blind. She had heart and circulation problems and had several procedures done in an attempt to treat them. She wore a pacemaker. And her TIAs were frequent.

A needle biopsy would entail considerable risk for her. The needle could accidentally puncture her lung and, because of her severely limited lung capacity, she could die as a result. And if the biopsy discovered the mass was malignant, then what? She was so frail, she would not survive either surgery or chemotherapy.

I made up my mind. I went back to the hospital and told the physician who had been attending my mother what I had been thinking. I then asked her: "If it were your mother, what would you do?"

"I would not do the biopsy," she said

That settled it. I canceled the biopsy and went to see my mother to tell her the news. She was extremely relieved.

I tell this story because it illustrates something that is being left out of the health care debate. From reading about it in the news, one would think it was all about providing coverage for the uninsured and making sure you could keep your doctor.

My parents had the best health care coverage imaginable. They were on Tricare for Life, a health plan for retired members of the armed forces and their spouses. Tricare picked up the entire tab for whatever Medicare didn't cover. It was so complete, about the only "medical" expenses they had during their last years (until they entered assisted living) were co-payments for prescription drugs and the cost of renting a television during their hospital stays.

Nevertheless, I don't believe the system served them well.

A few months after the needle biopsy incident, I read Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, by Annapolis author Shannon Brownlee. I wish President Obama and every member of Congress would read it. Perhaps they wouldn't be in such a hurry to push through a "Tricare for All."

A question that is not being asked is: Knowing that the results would not be actionable, why did doctors order a needle biopsy in the first place? Ms. Brownlee supplies an answer to that question and some others I had.

Three-and-a-half years earlier, another TIA had sent my mother to another hospital. There, they decided to do an aortic catheterization. The cost, including a hospital stay of six days, was more than $28,000. It didn't stop her TIAs.

Ms. Brownlee reported on a 2007 study by the Veterans Health Administration that found that the "vast majority" of invasive cardiac procedures such as this "are no more effective at preventing heart attacks and death" than treating the condition with drugs and counseling.

So why are they done - and why was it done to my mother? "The answer to this question is complicated by several factors," says Ms. Brownlee, "not the least of which is the handsome compensation they receive for every stent, catheterization, and angioplasty they perform."

There is a kind of moral hazard problem here. A physician who knows that a procedure is not going to take any money out of a patient's pocket is going to be more likely to order the procedure, even if he thinks it is only of marginal benefit. Especially if he's worried about being sued.

And this is a problem because invasive procedures and diagnostic tests are assaults on the body. Even a seemingly harmless CT scan bombards the body with potentially lethal radiation. And hospital stays can be dangerous as well, especially for the elderly. Both my mother and my father contracted staph infections during hospital stays.

Understand, I am not suggesting that necessary care be withheld from the elderly. But I am suggesting that we do not subsidize unnecessary procedures, especially when they are risky to the patient. (And I would also suggest that meaningful tort reform be enacted so that physicians don't feel the need to practice "defensive" medicine.)

The American Medical Association, which opposed both Medicare and Medicaid when they were proposed, has endorsed the health care plan working its way through the House of Representatives. Why is the AMA supporting this plan when it opposed the two earlier ones? The fact that the medical profession profited handsomely from Medicare and Medicaid provides a clue.

And it ought to raise a red flag.

Phil Manger lives in Cockeysville. His e-mail is pmanger@comcast.net.

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