Overtreated

David Leonhart proclaims Shannon Brownlee's Overtreated to be "the economics book of the year." It also fits into the strange category of book I would recommend even though I haven't actually read it. You see, even though I haven't read her book, I have read several reviews describing it -- not all of them quite as enthusiastic about it as Leonhart's -- and they make it clear that her perspective is interesting and important. What's more, various people who follow health care policy debates more closely than I do have told me that I have a Brownlee-esque point of view on health care policy, and so if I want to expound my views in a well-informed way I should read her book instead of talking out of my ass.

But if anything, the book's been promoted to me too highly! I read the article based on her book in the current Atlantic and it's great. So was this piece in The Washington Post and this op-ed in The New York Times. And I've heard her on the radio a couple of times, plus seen a bunch of people cite her work here and there on the internet.

Even better, the thesis is admirably clear: A system in which health care workers are paid for "providing health care" rather than for providing good health outcomes is a system that's set-up to generate lots of wasteful and counterproductive spending.

So you should read the book. And what's more, I'm going to buy a copy!

Comments

Looks interesting. I wonder whether she goes into detail on obstetrics in the USA, with our high C-section rates and mediocre outcomes?

Posted by bbartlog | December 19, 2007 2:32 PM

Well, if she is honest, then she will have to make it clear that the significant impact that the threat of lawsuits has on the medical community causes serious, system problems in care delivery. Defensive medicine is one reason health care is so expensive here - and with good reason. According to the lawyers, medicine is the only human undertaking in which every negative outcome is entirely due to "negligence" and is actionable. If people held our politicians to the same performance standard that the lawyers claim your local MD must meet in all cases and at all times, then Bush, Pelosi, Reid, etc would have been deposed years ago.

Posted by Eagle13 | December 19, 2007 2:42 PM

You see, even though I haven't read her book, I have read several reviews describing it

And since I get my knowledge from your blog posts, I think this will work out great.

Posted by Delicious Pundit | December 19, 2007 2:43 PM

Think about just how hard it is to separate good health prior to treatment from good health outcomes after treatment. Outcome metrics are tough to design in a way that doesn't create perverse incentives. This is the No Child Left Behind testing problem all over again.

This isn't an argument against using outcomes, but it *is* an argument (and a strong one) against putting too much payment weight on them.

Posted by mq | December 19, 2007 2:43 PM

"and so if I want to expound my views in a well-informed way I should read her book instead of talking out of my ass."

But I thought you wanted to be a pundit?

Posted by Chris | December 19, 2007 2:46 PM

I read the Leonhart column and thought, "Here we go again." I spent a short time as a federal bureaucrat working for HHS, and I recall that back then (late '80s) people in that environment were talking about the problem of "over-utilization" and the need for "capitation," i.e. rationing health-care dollars on a per-person basis, as the magic bullet to contain costs. If you impose strict limits on how much you can spend, then you'll sure control costs!

Now I've been a college professor at a public university for 10 years, and my family (including kids) are on my job-based health coverage. I've got to tell you: no one in my family has ever experienced the kind of spendthrift doctors that Leonhart is convinced are all over the place, handing out expensive procedures like candy. My wife and I have often had to struggle to get basic, sensible prescriptions and procedures, both for ourselves and for our kids. And most people, hearing of what I do for a living, probably would think I have pretty good health coverage.

Point two: The idea that patients "overutilize" because they feel like it's all free is bunk. Haven't these people ever heard of cost-shifting? Anything beyond a basic check-up costs real money out of your pocket, folks.

Now, I know all about needless c-sections. And maybe in south Florida and Arizona there are docs chasing after Medicare patients offering all kinds of lavish treatments and referrals. But overutilization is no doubt sectoral--concentrated among certain populations of patients and doctors, and focused on certain procedures--rather than what most patients, I would guess, experience. Maybe Brownlee is careful with her evidence; I haven't read her book. But it's obvious that plenty of people will use anecdotes and partial data to argue that people in general just have too much access to health care, and Brownlee should know that. Her book is certainly titled and packaged in a way that seems designed to lend itself to such distortions.

Posted by Doug | December 19, 2007 3:02 PM

"Well, if she is honest, then she will have to make it clear that the significant impact that the threat of lawsuits has on the medical community causes serious, system problems in care delivery. Defensive medicine is one reason health care is so expensive here - and with good reason. According to the lawyers, medicine is the only human undertaking in which every negative outcome is entirely due to "negligence" and is actionable."

I'll be reading this book, but the BIG reason why health care is so expensive here isn't lawsuits, it is because...the USA is an expensive place to do business.

There really is no other way to explain it. A surgery that costs $30,000 in the United States costs $5,000 in Singapore - and that's including the flight there/back, more nursing care, and a nicer room. Why?

Because to build a hospital here costs a lot of money, from the labor to the architect fees, not to mention the actual materials. Then you've got to staff the place...with techs and janitors that make $9.00/hr here, but $20/day overseas. Not to mention the nurses, radiology techs, physical therapists. Heck, even the cooks and laundry people.

It costs a hospital in Boston ~$350,000/yr for a radiologist who works 40 hours a week, and reads films on a PACS system - computerized. The same job can be done by a guy in Banglore for $35,000 a year - same training, same experience.

And we're talking about lawsuits?

Posted by GtheK | December 19, 2007 3:03 PM

I've seen stories in the news over the last year or two about hospitals experimenting with charging flat fees for surgeries and all followup care, including additional surgeries resulting from complications. Costs go down over all, with better results across the board--albeit in limited trials thus far.

This seems to me like a fantastic idea, a perfect example of Brownlee's reasoning, and it's an issue I'd like to see addressed in any national health care plan. If this truly works as well as it appears to--and more trials are necessary to determine this--it really should be mandatory.

Posted by R Johnston | December 19, 2007 3:07 PM

As alluded to above, while I understand the idea behind the thesis, the way it is stated is ridiculous.

All a provider can do is provide "health care." A health care provider (which I am) cannot provide an outcome. All I can do is make the diagnosis and treat the patient according to my training, and hope that the the outcome is good. And if I am reasonably smart and well trained the care I provide will lead to good outcomes, but there is no gurantee. Sometimes bad outcomes happen even when the patient has receieved the proper treatment and has not been the victim of medical errors. Certainly we should have a system that is set up so that what is provided is "good health care" vs. "bad health care", but saying that the system needs to provide "good outcomes" is silly unless the system is omnipotent, in which case we wouldn't be having this debate.

Posted by DP | December 19, 2007 3:08 PM

No offense, DP, but "health care" today stinks. I am not sure what they train you to do, but my experience is that doctors will prescribe just about anything based on the patients' description of symptoms without ordering up any tests or trying to figure out which of several similar conditions might cause the symptoms. (Medicate first, observe effects of medication later to determine diagnosis)

When I went to the doctor for fatigue, they wanted to give me anti-depressants. When my fatigue got worse they wanted to add anti-anxiety. When my stomach hurt they said "antibiotics!" When I had skin problems, they offered steroid creme. Four doctors saw four conditions based on the few symptoms they wanted to focus on. No one bothered to look at the big picture, and say, order a blood test for Celiac Disease - one condition that could explain ALL of the symptoms.

I'm extremely grateful that I turned down those drugs and endured the pain of the symptoms, because it was only by doing so that I was motivated to research the underlying cause. If I had been doped up on things designed to make me feel better, I would just be deteriorating with a smile on my face.

And now, without any "health care," I'm in better health than I've known my whole life.

Posted by underground | December 19, 2007 3:20 PM

I have never been able to follow the whole defensive-medicine riff.

Put it this way: Suppose I go to the emergency room and the doctor concludes that there are (say) 99 chances out of a hundred that I have Condition A and one chance out of a hundred that I have Condition B. Testing for Condition B costs money, but if I have it and the doctor treats me for Condition A, I will die.

Excuse me, but I want the test! I would hope that the doctor would order it anyway, because he would prefer for me not to croak, but if it takes the threat that my heirs will sue him if he doesn't, then hurrah for malpractice litigation.

Obviously, testing all 100 of us is going to drive up everybody's insurance rates. But I really don't find that unacceptable is the alternative is the unnecessary death of 1 in 100 patients. Even if it isn't me.

Posted by roac | December 19, 2007 3:22 PM

Dr. Wennberg's work is well known in the health policy field and has been for years. It's very good that this book will bring this information to a broader audience.

It is not that docs are offering "lavish treatments and referrals" in some areas of the country and not others. It's that the standard of care is different in different parts of the county for the same condition and there is no evidence that the more expensive treatments produce better results. Quite a lot of medical treatments are not based on evidence of efficacy, but are done because that's the way the physician's peers treat people and so he/she does the same thing. It is the local standard of care that sets the floor and ceiling.

Posted by SteveH | December 19, 2007 3:24 PM

But what is on page 69??

Posted by catclub | December 19, 2007 3:25 PM

I am not defending the system or saying it is great, and I certainly can't speak to your experiences (other than noting that failing to diagnose celiac sprue is a common anecdote about how the health care system sucks). I am only pointing out that Matt's thesis that we need to have a system that provides "good outcomes" as oppsed to providing good care doesn't really make any sense.

Posted by DP | December 19, 2007 3:26 PM

Well, I'll have to admit I'm no expert in this subject, and never even thought much about health care policy until the last few years.

But from everything I've seen, it's rather obvious that something pretty close to government health care/socialized medicine/single payer/whatever would be a gigantic improvement over our current crazy system, though actually getting there politically is pretty tricky because of all the "vested interests" and the hundreds of billions they annually extract from the productive sectors of the American economy.

It's hardly surprising that Europeans these days grow quite a bit taller than Americans of similar ancestry. Every biologist knows that a heavy infestation of parasites can reduce the physical size of the members of a herd.

Posted by RKU | December 19, 2007 3:27 PM

But from everything I've seen, it's rather obvious that something pretty close to government health care/socialized medicine/single payer/whatever would be a gigantic improvement over our current crazy system...

Why is this obvious?

Creating a legal health monopoly alone seems dangerous -- putting the government at the helm even more so. It doesn't take a libertarian to worry that your experience getting health care will come to resemble your experience at the DMV. Or that the paperwork required will start to feel like doing your taxes.

Posted by Brad L | December 19, 2007 3:38 PM

"Well, if she is honest, then she will have to make it clear that the significant impact that the threat of lawsuits has on the medical community causes serious, system problems in care delivery. Defensive medicine is one reason health care is so expensive here "

The high estimate for defensive medicine costs by ardent tort reform advocates is 9% of medical GDP. Eliminating even that entire amount does not make a big dent in health care costs, and it is puny compared to what health care costs are projected to be in the future.

Posted by Njorl | December 19, 2007 3:40 PM

This thread reminds me of Tony Kornheiser's standing offer to his friends who want a bookflap blurb - "I haven't read it, but I hear it's very good."

Posted by Njorl | December 19, 2007 3:42 PM

It doesn't take a libertarian to worry that your experience getting health care will come to resemble your experience at the DMV.

The funny thing is, I've never left the DMV without having gotten exactly what I went there for in the first place. But I've often left medical offices with incomplete information, prescriptions that were inappropriate and/or illegible, and just as much resentment of condescending, unresponsive staff as any government agency has produced (billing clerks and staff nurses are particularly annoying IME). The worst was a very upscale dermatologist's office, and you'd think that a highly cosmetic specialty would work some of that free-market service magic, but nope.

Posted by latts | December 19, 2007 3:54 PM

But I've often left medical offices with incomplete information, prescriptions that were inappropriate and/or illegible, and just as much resentment of condescending, unresponsive staff as any government agency has produced (billing clerks and staff nurses are particularly annoying IME).

I've fired a couple of doctors for different forms of poor service. Never had much luck doing that to the DMV, though when I moved states, it was better. (I envy your DMV experience. I've had the gamut, but some truly memorably bad experiences).

Posted by Brad L | December 19, 2007 4:10 PM

Brad L apparently had never actually experienced dealing with health care. DMV? Heck much ebtter than being in phone limbo trying to figure out if your Explanation of Benefits form not fully covering a procedure will lead to a write off, a partial write off, or no write off. And finding yourself 90 days past due because your insurance company took 90 days to process a claim.

And tax paper work is a cinch compared to anything related to health insurance when you get at least three bills for any given procedure.

Posted by Rob | December 19, 2007 4:13 PM

Sigh... I can complain about the DMV, and thanks to government transparency, I can find out the name of every single person up the food chain. I can also vote against officials who allow bad service, make a point of promising to work for their opponents, write letters to the editor about how terrible the service We the Taxpayers fund is, and otherwise broadcast my dissatisfaction without fear of repercussions (unless it's the Bush administration, I guess).

Can't do that to insurers, I've noticed-- it's hard to get them to reveal names, much less the management structure. I've fired several doctors-- the dermatologist in question because he'd contributed $2K to Bush, and with that affiliation it's no wonder his staff were assholes-- but it's not like they care. They're just as rotten as any bureaucrats, and considerably more difficult to frighten.

Posted by latts | December 19, 2007 4:45 PM

Brad L apparently had never actually experienced dealing with health care.

I just had a colectomy, jerko.

I've had a wide variety of health care experiences, and the deciding variable regarding experience appears to be the quality of the health insurance company. Some are quite good (Aetna), some are mediocre (Great West), some you should run screaming from (whichever flavor of BC/BS I had).

None of these things changes my opinion of the DMV. It is not ignoring the current health care problems to wonder whether "government health care/socialized medicine/single payer/whatever" is the answer.

Posted by Brad L | December 19, 2007 4:50 PM

Sigh... I can complain about the DMV, and thanks to government transparency, I can find out the name of every single person up the food chain.

This is true, and fair as far as it goes. But monopolies and government institutions have little interest in being responsive to complaints. Holding the power of the vote helps some, but at the end of the day it isn't (to my mind) enough corrective power for anything but the most egregious of abuses. I don't think I could generate enough political momentum to change the DMV, no matter how hard I tried.

Can't do that to insurers, I've noticed-- it's hard to get them to reveal names, much less the management structure.

The system is broken. I'm just not buying the proposed solution here.

Posted by Brad L | December 19, 2007 4:58 PM

there is no evidence that the more expensive treatments produce better results.

Not true:

http://www.nber.org/papers/w13301

Posted by mq | December 19, 2007 5:00 PM

Re: I've fired a couple of doctors for different forms of poor service.

Really? You pulled their medical licenses? I doubt it. And if you just took your business elsewhere, well, good for you, you should! But don't think those doctors missed you. There were plenty more patients in the pipeline for them. As for DMVs, the remedy for a badly run government office is to go to another one (ditto for chain stores, resturants etc.)

Re: But monopolies and government institutions have little interest in being responsive to complaints.

Actually, ambitious politicians have long since learned that one path to electability is cleaning the DMV and other government offices which the voters frequently must deal with. This is partly why DMV services (along with post offices, the IRS etc) have gotten a lot better over the last twenty years-- the IT revolution being another big reason for that. I haven't had a complaint with a DMV office since my earlier years as a driver (licensed in 1983). Indeed, the institutions that rank high on my Hate List are all private businesses, consisting of two cable companies, a certain online travel company, a cell phone service company, and various fast food resturants and convenience stores.

Posted by JonF | December 19, 2007 7:21 PM

I remember when I started having some difficulty breathing 5 years ago. I was 28 years old and I went to 6 doctors to figure out what was wrong with me. They all said different things from anxiety attacks to asthma. I did a variety of tests as well and was given an inhaler. Well, I started to do research online and guess what I found: I might have acid reflux. I was 15 lbs overweight so I started taking TUMS and working out. I lost the weight and the breathing problems. I did not even count the money I spent on tests and visits. It was ridiculous. The thing that annoys me with physicians the most is this though: They treat you like a customer but they do not want to be treated like a business. If they keep you waiting, no one comes out and tells you: "Hey, this is on me today" but if you don't pay, they make sure the collection agency gets your file.

Posted by Joshua | December 19, 2007 8:44 PM

Really? You pulled their medical licenses? I doubt it. And if you just took your business elsewhere, well, good for you, you should

You clearly understood what I meant; I think if you told someone that you "fired your lawyer" (or agent, or accountant), they would not assume you meant that you had their license revoked. Just that you are no longer paying them to do a job, which is a pretty acceptable definition of the word "fired."

Whether they miss me isn't the point, though. I'm sure McDonald's didn't miss my business when I stopped eating there, either, relatively speaking. What's more important is that I don't miss them.

As for DMVs, the remedy for a badly run government office is to go to another one

Really? You just went to another government? (Hey, this trick is kinda fun, if pointless.)

I'll just say that my experience does not match your observation, although generally the IT boom has helped tremendously, it's true. If you think the way to win this argument is with "the DMV isn't that bad," it's an uphill climb.

Indeed, the institutions that rank high on my Hate List are all private businesses, consisting of two cable companies...

Obviously, there are bad private companies. In the case of cable, I'd argue that these are near-monopolies (they were worse before satellite made inroads), which is not surprising to me.

Posted by Brad L | December 19, 2007 9:31 PM

yeah, the herd mentality for treatments is ridiculous. Medicine is really voodoo, which is especially bad since there is quite a lot of published studies on how best to treat things.

Posted by yoyo | December 19, 2007 10:51 PM

I LOVE the DMV!!! I get to go there. I don't get to go to doctors. Or dentists.

Posted by Luke | December 19, 2007 11:27 PM

Someone may have mentioned it, but I didn't see it.

I think the correct terminology for your current predicament, Matt, is "I've read it, but not personally."

Posted by Loren Michael | December 20, 2007 8:57 AM

Someone may have mentioned it, but I didn't see it.

I think the correct terminology for your current predicament, Matt, is "I've read it, but not personally."

Posted by Loren Michael | December 20, 2007 9:07 AM

what's frustrating about this debate is that people generalize from their specific experience and that colors their take on health care. The facts remain that health care costs are rising at an unsustainable rate, that there are a lot of divergent interests involved, and that until costs are fully shifted back onto the health care user (for all, no "freebies"), there is not a ghost of a chance in hell of fixing this problem. Tax policy, improved technology, and the expectations of gold-standard/at-any-cost care has driven us to a point of making very stupid policy mistakes, whether it is continuing the current "insurance" scheme or pretending the government will somehow fix the problem.

Posted by mike c | December 20, 2007 9:14 AM

"Good outcomes" sounds nifty until you start to define what you mean. CMS has been trying to do this with hospitals, nursing homes and home care for the past several years -- and publishing "report cards" that grossly mislead and confuse the public -- and has met with laughable results. In my world (home care and hospice) there often are no good outcomes: You're in hospice because you're going to die soon, or you're receiving home care because your limbs don't work -- never have, never will. Another problem is that the wonks who create the outcome measures almost never have any actual experience caring for patients and are not terribly interested in listening to people who do.

Before we start blaming doctors and nurses for providing willy nilly care -- according to David U. Himmelstein, M.D,, at the
Harvard Medical School, "Americans have fewer physician visits and lower hospital use per capita than other nations. Surveys of English-speaking countries show that Americans face the greatest barriers to care." -- perhaps we should look at health insurance and HMO profit margins. United Health -- one HMO -- paid its CEO $1.6 billion in 2006. Damn.

Posted by Russell King | December 20, 2007 10:31 AM

> there is no evidence that the more expensive treatments produce better results.

> Not true:

> http://www.nber.org/papers/w13301

I have read the abstract and more about that study, but not enough to know if it really says what you say it says. The first thing, it doesn't deal at all with day-to-day health care use. It's solely an analysis of emergency care. Might areas that spend a lot more on emergency care, have better trained paramedics instead of EMTs, have better equipped ambulances and ERs, produce better results than areas that spend less? Sure.

(I have worked on EMS issues off and on for the last several years and it is the one area of health care where I can say, with a lot of confidence, that the US beats the rest of the world.) However, "Doyle's results also confirm earlier findings of little relationship between spending and mortality among the populations the health care systems are designed to serve."

So, more spending great for emergency care apparently, otherwise not so much.

Posted by SteveH | December 20, 2007 12:58 PM