Do Americans really need the amount of treatment that our health care system is used to providing?
As stay-at-home orders ease and cities reopen for business, many doctors and hospital administrators are calling for a quick return of health care to pre-pandemic levels. For months now, routine care has been postponed. Elective procedures — big moneymakers — were halted so that hospitals could divert resources to treating Covid-19 patients. Routine clinic visits were canceled or replaced by online sessions. This has resulted in grievous financial losses for hospitals and clinics. Medical practices have closed. Hospitals have been forced to furlough employees or cut pay.
Most patients, on the other hand, at least those with stable chronic conditions, seem to have done OK. In a recent survey, only one in 10 respondents said their health or a family member’s health had worsened as a result of delayed care. Eighty-six percent said their health had stayed about the same.
Admittedly, postponing health care had terrible health consequences for some patients with non-Covid-19 illnesses, such as those with newly diagnosed cancers that went untreated because outpatient visits were canceled, or because patients avoided going to the hospital out of fear of contracting the coronavirus. The spike in deaths in major cities like New York during the crisis almost certainly includes such patients.
Still, a vast majority of patients seem to have fared better than what most doctors expected. It will probably take years to understand why. Perhaps patients mitigated the harm of delayed care by adopting healthful behaviors, such as smoking less and exercising more. Perhaps the huge increases in stress were balanced out by other things, such as spending more time with loved ones.
However, there is a more troubling explanation to consider: Perhaps Americans don’t require the volume of care that their doctors are used to providing.
It is well recognized that a substantial amount of health care in America is wasteful, accounting for hundreds of billions of dollars of the total health care budget. Wasteful care is driven by many forces: “defensive” medicine by doctors trying to avoid lawsuits; a reluctance on the part of doctors and patients to accept diagnostic uncertainty (which leads to more tests); the exorbitant prices that American doctors and hospitals charge, at least compared to what is charged in other countries; a lack of consensus about which treatments are effective; and the pervasive belief that newer, more expensive technology is always better.
One of the most significant factors in wasteful health care is having too much supply of health care per capita in certain areas. In specialist-heavy Miami-Dade County, for example, Medicare spends more than twice per person what it spends in Santa Fe, N.M., largely because there is more per capita utilization of doctors’ services. Sadly, more care doesn’t always result in better outcomes.
If beneficial routine care dropped during the past few months of the pandemic lockdown, so perhaps did its malignant counterpart, unnecessary care. If so, this has implications for how we should reopen our health care system. Doctors and hospitals will want to ramp up care to make up for lost revenue. But this will not serve our patients’ needs.
The start-up should begin with a renewed commitment to promoting beneficial care and eliminating unnecessary care. Most doctors recognize the importance of this distinction, even if we don’t always act on it. In a survey a few years ago, two-thirds of doctors in the United States admitted that between 15 percent and 30 percent of health care is probably unnecessary.
Medical societies already produce lists of procedures that are essential and those that are better avoided. The latter include M.R.I. scans for most lower-back pain and nuclear stress tests when there are no signs of heart disease. As hospitals and clinics reopen for non-Covid-19 care, such lists should be more widely publicized.
Patients have an important role to play, too. Studies suggest that up to 20 percent of surgeries in some specialties are unnecessary. If your surgery was postponed because of the pandemic, it is worth having a conversation with your doctor about whether it is still needed. Despite the complexity of disease today, ailments sometimes do get better by themselves. And in some cases, scheduled surgeries weren’t necessary in the first place.
Many institutions are using this difficult time in our nation’s history to make changes. The health care system should do the same. The pandemic has given us a glimpse of a world in which business as usual in our health care system was upended. It has also provided an opportunity to start up again in a healthier and more financially responsible way. Reflexively returning to the status quo may be good for our bottom line, but it won’t serve our patients well.
Sandeep Jauhar is a cardiologist, a contributing Opinion writer and the author, most recently, of “Heart: A History.”
Bron: NYT / 22 juni 2020