No. 1 Book, and It Offers Solutions

By DAVID LEONHARDT
In 1967, Jack Wennberg, a young medical researcher at Johns Hopkins, moved his family to a farmhouse in northern Vermont.
Dr. Wennberg had been chosen to run a new center based at the University of Vermont that would examine medical care in the state. With a colleague, he traveled around Vermont, visiting its 16 hospitals and collecting data on how often they did various procedures.
The results turned out to be quite odd. Vermont has one of the most homogenous populations in the country — overwhelmingly white (especially in 1967), with relatively similar levels of poverty and education statewide. Yet medical practice across the state varied enormously, for all kinds of care. In Middlebury, for instance, only 7 percent of children had their tonsils removed. In Morrisville, 70 percent did.
Dr. Wennberg and some colleagues then did a survey, interviewing 4,000 people around the state, to see whether different patterns of illness could explain the variations in medical care. They couldn’t. The children of Morrisville weren’t suffering from an epidemic of tonsillitis. Instead, they happened to live in a place where a small group of doctors — just five of them — had decided to be aggressive about removing tonsils.
But here was the stunner: Vermonters who lived in towns with more aggressive care weren’t healthier. They were just getting more health care.
Dr. Wennberg would eventually move to Dartmouth and, over the last 30 years, has done versions of his Vermont study for the entire country. Again and again, he has come up with the same broad result. And that result holds the key to health care reform — how to spend less on health care while not making the population any less healthy.
Dr. Wennberg’s story forms the backbone of “Overtreated,” by Shannon Brownlee, which is my choice for the economics book of the year. This was another very good year for economics books. Alan Greenspan wrote a best-selling memoir that was really two books, one an autobiography, the other an exposition on the virtues of the free market. Robert H. Frank and Robert Reich wrote thoughtful books about reversing the excesses of that free market. Paul Collier offered a clearheaded argument for reducing global poverty in “The Bottom Billion.”
But I’m going with Ms. Brownlee’s book because it’s the best description I have yet read of a huge economic problem that we know how to solve — but is so often misunderstood.
As you’ve doubtless heard, this country spends far more money per person on medical care than other countries and still seems to get worse results. We devote 16 percent of our gross domestic product to health care, while Canada and France, where people live longer, spend about 10 percent.
Some of this difference is unavoidable. The United States does more than its share of medical research and bears much of those costs. It also has a diverse, economically unequal population, which, in turn, leads to a diverse and complicated set of health problems.
But health care spending simply can’t continue to rise at its current pace. If it did, it would “eventually overwhelm both the federal budget and workers’ paychecks,” as Peter Orszag, director of the Congressional Budget Office, told me. “Slowing such growth is the single most important step we can take to assure our fiscal future and lift a growing burden on workers.”
Fortunately — if that’s the right word — there is an obvious candidate for cost-cutting: all that care that brings no health benefit. It’s not hard to find examples. Scientific studies have shown that many treatments, including spinal fusion, routine episiotomies and neonatal intensive care, are overdone. These procedures often help specific subsets of patients. But for a lot of people, and “Overtreated” is full of stories, the treatments are a modern-day version of bloodletting.
“We spend between one fifth and one third of our health care dollars,” writes Ms. Brownlee, a senior fellow at the New America Foundation and former writer for U.S. News & World Report, “on care that does nothing to improve our health.”
Worst of all, overtreatment often causes harm, because even the safest procedures bring some risk. One study found that a group of Medicare patients admitted to high-spending hospitals were 2 to 6 percent more likely to die than a group admitted to more conservative hospitals.
Why is this happening, then?
Above all, it’s the natural outgrowth of our fee-for-service health care system. It turns doctors into pieceworkers, as Ms. Brownlee puts it, “paid for how much they do, not how well they care for their patients.” Doctors and hospitals typically depend on the volume of work for their income, and they are the gatekeepers who decide when work needs to be done. They also worry about being sued if they do too little. So they err on the side of overtreatment.
Patients play a role, too. We’re entranced by the wonders of modern medicine and fooled by our byzantine health insurance system into thinking that we’re not really paying for all those unnecessary spinal fusions.
The typical book about current affairs is better at describing problems than solutions. But there is a nice surprise at the end of “Overtreated.” (If you find yourself wishing the book had fewer anecdotes, I’d suggest you skip to the end rather than putting it down.) In plain English, Ms. Brownlee lays out an agenda for reform that is usually confined to academic journals.
It includes some steps that should be widely popular, like giving doctors incentives to explain the risks and benefits of procedures more clearly than they do now. Research has shown that patients frequently decide against marginal care when they know the true risks and benefits. Malpractice laws would also need to be changed so doctors were not sued by patients who later changed their minds.
Other solutions would be more difficult — because medical evidence is often murky, because hospitals and insurers would fight to keep their revenues and because most Americans think it’s the other guy who’s getting unnecessary treatment. These are the reasons that presidential candidates don’t focus on wasteful treatment.
But models for reform are out there. Hospitals that don’t use the fee-for-service model, like those run by the Veterans Health Administration, are already getting better results for less money. They closely track their performance — that is, the health of their patients — and motivate employees to improve it.
As I’ve written before, there is nothing wrong with devoting a large chunk of our economy to medical care. Since the 1950s, doctors have made incredible progress against diseases that were once inevitably fatal. That progress is probably the finest human achievement of the last half century.
If we weren’t wasting so much money on overtreatment, it would be a lot easier to repeat the achievement over the next half century.
E-mail: leonhardt@nytimes.com
-- December 19, 2007 Economic Scene

"This book could save your life. In gripping detail, Shannon Brownlee explains how well-insured Americans get much more high-tech medical care -- CT scans, angiograms, and the like -- than they need, enriching the hospitals and doctors who provide it, but driving up the overall costs of health care and often endangering patients' lives. Brownlee clearly shows in this important book that overtreatment, like undertreatment, is very bad medicine."
-- Marcia Angell, M.D., former editor-in-chief of the New England Journal of Medicine and author of The Truth About the Drug Companies

"In the blizzard of books on our healthcare system, Shannon Brownlee's is unique in its provocative argument that individuals and nation suffer from misguided and costly treatments. Patients, physicians, and policy makers would do well to consider her evidence as an important prescription for reform."
--Jerome Groopman, M.D., Harvard Medical School and author of How Doctors Think

Journalist Brownlee blames America's sky-high healthcare costs on expensive treatments imposed by doctors on patients all too ready to accept or even demand them.

At a time when presidential candidates are asked how they plan to pay for universal healthcare coverage, the author provides reams of data to back up her contention that the real issue is the "dysfunctional, unfair and spectacularly expensive system" we're already paying for. Unnecessary care is rampant, she concludes. Doctors are coaxed, conditioned or warned that they must prescribe drugs or tests, refer to specialists, put patients in the hospital, operate. If this excessively aggressive approach involves a new drug, device or machine, so much the better: Medicare or another insurer will pay generously for high-ticket items, but not for prevention and advice. Some patients benefit; many do not. Medicare patients living in high-cost, high-care regions are no healthier than their peers in lower-cost, less-care regions.
For this conclusion, as for others in the book, Brownlee relies on data from the Dartmouth Atlas of Health Care, an annual compendium that tallies who gets what procedure for what ailment in each region of the country. Overtreatment is a national problem, the author states. Precipitating factors include aggressive physicians; litigious patients ready to sue over any omission; and hospital administrators adding (and filling) surgical wings or ICUs to pay for emergency departments that operate at a loss. Also contributing to the mess are direct advertising to consumers and control of clinical trials by Big Pharma, insufficiently monitored by weak federal agencies charged with regulation and with reviewing the evidence of what works. What to do? Brownlee points to the Veterans Health Administration, which rose from rock bottom in the mid-1990s to become a model health-care provider. Other institutions could achieve similar results, she believes, by implementing a strate gy of "CARE": coordination, accountability, electronic medical records and evidence.

A bombshell of a book: must reading for consumers, their political representatives and all those White House contenders.
--Kirkus Reviews (starred review)

Award-winning health and medicine writer Brownlee notes that Americans spend between one-fifth and one-third of health-care dollars on unnecessary treatments, medications, devices, and tests. What’s worse, there are an estimated 30,000 deaths per annum caused by this unnecessary care. The reason for what amounts to a national delusion that more care is better care is rooted, she says, in a build-it-and-they-will come paradigm that rewards doctors and hospitals for how much care they deliver rather than how effective it is. In a step-by-step deconstruction of America’s improvident health-care system, Brownlee sheds light on events, attitudes, and legislation in the twentieth century’s latter half that led to this economic nightmare. With the skill of a crack prosecuting attorney, she cites specific cases of physician and hospital fiscal abuse. Her aim is broad but not scattershot as she hits not just docs and hospitals but private insurers, Medicare, patients, medical device manufacturers, and pharmaceutical companies by, for instance, quoting a pharmaceutical salesperson who confesses financing a physician’s swimming pool to get the doc to write more prescriptions. She is not all bad news, though, for she posits models that could be adapted to create a nationwide health-care system that conceivably could staunch the current fiscal hemorrhaging. If only.
--Booklist (starred review)

"With her razor-sharp analyses, Brownlee disentangles the
paradoxes of today's health care mess and turns every assumption on its head. She will forever change the way you view health care while re storing your hope for its future. This book is an important read for anyone interested in health care reform, which, in this day and age of overtreatment, should be all of us."
-- Pauline Chen, M.D., author of Final Exam: A Surgeon's Reflections on Mortality

"Overtreated will scare you. And that's a good thing. In this vivid and arresting tour of medicine in America, Shannon Brownlee shows why the care that is supposed to make us healthier frequently makes us sicker instead. At a time when health care reform is atop the political agenda again, this book should be required reading -- not only for every lawmaker and medical professional, but for every voter and patient, too."
-- Jonathan Cohn, author of Sick: The Untold Story of America's Health Crisis

"Finally, someone willing to expose the dirty little secret of U.S. health care. If you have insurance you will certainly get too much health care, and when it comes to medicine more is definitely not better! Overtreated will open your eyes to the problems and point the way to the answers."
-- Susan Love, M.D., author of Dr Susan Love's Breast Book and President and Medical Director, Dr Susan Love Research Foundation

Contrary to America's common belief that in health care more is more--that more spending, drugs and technology means better care--this lucid report posits that less is actually better. Medical journalist Brownlee acknowledges that state-of-the-art medicine can improve care and save lives. But technology and drugs are misused and overused, she argues, citing a 2003 study of one million Medicare recipients, published in the Annals of Internal Medicine, which showed that patients in hospitals that spent the most "were 2% to 6% more likely to die than patients in hospitals that spent least." Additionally, she says, billions per year are spent on unnecessary tests and drugs and on specialists who are rewarded more for some procedures than for more appropriate ones. The solution, Brownlee writes, already exists: the Veterans Health Administration outperforms the rest of the American health care system on multiple measures of quality. The main obstacle to replicating this model nationwide, according to the author, is a powerful cartel of organizations, from hospitals to drug companies, that stand to lose in such a system. Many of Brownlee's points have been much covered, but her incisiveness and proposed solution can add to the health care debate heated up by the release of Michael Moore's Sicko.
--Publishers Weekly (starred review)

Readers who have thrown out recalled, expensive prescription drugs, grieved at the death of a friend who died from a "minor" surgical procedure, or agonized over the hospital care experienced by their dying, elderly parents will experience the shock of recognition in Overtreated. Science journalist Brownlee (Atlantic Monthly, NewRepublic) has mined medical journals, reports from authoritative health care organizations, and troubling personal narratives by doctors and patients to present a stunning but reasoned picture of the out-of-control, inefficient, and often tragically ineffective U.S. health care system. Compared with those who live in other First World countries, Americans see more specialists, receive more days of hospital care, and undergo far more diagnostic procedures. Paradoxically, the result of this surfeit is frequently a less favorable—if not fatal—medical outcome. Stories of the perverse economic incentives for Medicare and private health insurers, poor oversight on the part of the Food and Drug Administration, and common medical procedures based on no more scientific evidence than bloodletting are interwoven in a compelling call for patient-centered, evidence-based health care—admittedly, not a modest proposal. More optimistically, Brownlee points to institutions that already use these measures, including, surprisingly, the Veterans Health Administration. This rousing call for change, accessible to general readers, is recommended for all libraries.
—Kathy Arsenault, Univ. of South Florida at St. Petersburg Library, LJXpress

As a primary care physician, I often feel like the voter drawing laughs from economists at cocktail parties - you know the one who keeps showing up at the polling booth out of some irrational conviction that a single vote might actually affect the outcome of a process controlled by much larger forces.
Picking up Shannon Brownlee's "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer" certainly didn't help. It's unpleasant, discouraging and confirms that sinking feeling we all recognize -- that the more technologically advanced and specialized our health-care system becomes, the worse we feel.
"Overtreated" is a necessary, if bitter, tonic. As the election season starts to take shape, we desperately need an unbiased examination of the mess we're in and some substantive ideas for fixing it. "Overtreated" delivers on both counts.
Brownlee, a well-respected medical journalist, uncovers some truly amazing facts. It turns out the likelihood of you being admitted to an ICU or having your gall bladder removed depends more upon where you live than how sick you are. This is partly because there is no proven "right" way of managing most medical conditions, so doctors tend to absorb the habits of the area where they train and practice.

Shannon Brownlee's Overtreated provides a welcome antidote to the narrow view that simply finding enough money to buy health insurance for all the uninsured would solve our health-care crisis. She reminds us that entrepreneurial medicine often drives physicians and other providers to do too much to patients, which can be bad for their health as well as for everyone's wallet. Doctors order costly imaging studies like MRIs and CAT scans when a careful history and physical exam would do. They administer courses of toxic chemotherapy (which account for over half the revenues of many oncology practices) to dying cancer patients in the absence of evidence that it will help. They manage heart disease with invasive procedures when much simpler regimens would work as well.

As Brownlee points out, the culprit here is not just the for-profit free-for-all that American medicine has become. Patients often demand the fanciest technology for its own sake, and physicians sometimes prefer to provide the newest and most complex treatments because they want to do everything possible for their patients. But these desires alone cannot explain the irrational technological exuberance of U.S. health care. Physicians in other advanced nations want to be on the cutting edge, too, and patients everywhere want the best care available. What is distinctive about our system is that it provides economic incentives that encourage doing the most expensive thing all the time to everyone who can pay for it or have it paid for. In most settings, there is little pressure to consider costs, and much reason for physicians, patients, and other decision-makers to maximize expenditures. In the effort to prevent unnecessary expenses, we have introduced new layers of care deniers, who sometimes deny coverage even for appropriate services. And so the world's most expensive health-care system paradoxically provides a great deal of medical care that isn't needed, while people who lack coverage cannot get even the most basic services. Overtreated is a must-read for all those (and there are many) whose main concept of "fixing the health-care system" is buying Blue Shield or Medicare for everyone.
—The American Prospect Shift Happens
Why is American's health-care system collapsing? Three books, three good answers.
October 30, 2007

In this exhaustive takedown of the U.S. health-care system, Brownlee argues that as much as one-third of the money we spend on care does not improve our health and may even harm or kill us. Though it sometimes overlaps with Michael Moore’s Sicko (the album Ronald Reagan made for the A.M.A. in the 1960s, which warned that Medicare could lead to a Stalinist dictatorship, makes a cameo in both), Overtreated eclipses Moore’s reporting and eschews his polemics. By piling on facts, Brownlee shows why Americans spend so much on health care yet are in measurably poorer shape than  the residents of just about every other developed nation.
—Conde Nast Portfolio.com By Jen Itzenson

http://www.portfolio.com/

Costly Tests, Useless Procedures Harm Patients, Boost Profits

Americans spend more per capita on health care each year than the Chinese spend on, well, everything. Do we really need so much?
In her alarming and intriguing book ``Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer,'' medical journalist Shannon Brownlee argues that we spend between $500 billion and $700 billion a year (out of some $2 trillion total) on care that does nothing to improve our health and sometimes damages it.
At the same time, Charles R. Morris reports in a very different book, ``The Surgeons: Life and Death in a Top Heart Center,'' that Americans now spend more money on repairing hearts than on new cars. But he barely questions the trend.
Brownlee gives each of her theme-based chapters an emotional core by rolling out a story -- the primary-care doctor financially and emotionally depleted by managed care, the drug rep who reformed, the toddler who died of a Third World condition, dehydration, at a first-class medical center.
Then she gets to the meat of her message. ``There is something deeply and disturbingly counterintuitive about the picture of American medicine that emerges from these examples,'' she writes of a woman who endured years of expensive specialists and surgeries when her Addison's disease could have been diagnosed with a simple blood test.
The book is full of research gems. A national study of Medicare patients suffering heart disease, colorectal cancer or hip fracture revealed that in the highest-spending regions, patients received 60 percent more care yet were 2 percent to 6 percent likelier to die.
Ohio Outdoes Canada
Consider that pricey MRIs and CT scans now lead doctors to treat conditions that never would have bothered their patients. Or that Ohio has more MRI units than all of Canada.
Or that the vast majority of invasive cardiology procedures aren't aimed at saving lives -- they're elective. Studies show that half a million of the angioplasty and stent procedures annually performed are of questionable value.
Or that our shameful lack of evidence-based medicine allows thousands of back-pain patients to undergo lower lumbar spinal- fusion surgeries each year despite a paucity of research demonstrating their efficacy. Or that abdominal CT scans haven't dented the 15 percent rate of unneeded appendectomies.
Brownlee directs her angriest critiques at Big Pharma and wasteful Medicare before wrapping up with a sterling example of success: the Veterans Health Administration, which outpaces fee- for-service Medicare on every measure of quality, and without long lines or care rationing.
Time to Change
It's time, Brownlee argues, to stop letting Pfizer enjoy a (2002) 28.4 percent profit return (versus Wal-Mart's 3.3 percent and General Electric's 10.7 percent); time to halt the 30 percent profit margin for manufacturers of implantable medical devices. What do we give up in return? ``The belief,'' she writes, ``that more medical care is always better.''
Unless, perhaps, you're in the hands of the top cardiac surgeons at New York's Columbia-Presbyterian Hospital. Charles R. Morris, an investment banker turned journalist (his last book was ``The Tycoons''), makes them the subject of ``The Surgeons.''
Morris's book has plenty to recommend it if you're a heart- disease patient or merely curious about the inner workings of a bypass machine. He embedded himself with the hospital's heart- surgery team to deconstruct medical miracles, chart the rise of catheter-based cardiology and examine the work lives of such stars as Craig Smith (who operated on Bill Clinton) and Mehmet Oz.
But though Morris is adept at explaining the fine points of cardiac surgery, he rarely casts a critical eye on the profession. And he admires his subjects without exploring who they are as people. There's a strong chapter about a 4-year-old heart patient who tragically loses her battle. But overall his prose seems emotionally distant -- bloodless, almost.

— By Joan Oleck
Oct. 22, 2007

http://www.bloomberg.com/apps/news?pid=20601088&sid=aMM6Rf0f4OzQ&refer=home

Medical journalists are beleaguered practitioners in today's fourth estate. They live with near-instantaneous deadlines for plucking the sound bite of the day from the cacophony of good and bad science that wells up in our literature. They are rewarded for creating the scare of the week. They are afforded so little time to dig into topics that a quotable statement from whoever is the most available expert is sufficient for validation and verification. They march to multiple drums: deadlines, editorial demands to "dumb it down," and producers who insist they infuse their coverage with energy. There may even be implicit constraints on investigative reporting not to bite the hands that feed them—no mean task given the marketing budgets of the biomedical industry. I have empathy for these journalists and disdain for the institution that requires them to sacrifice content to dissemination. It is the same emotion I have for clinicians whose feet are held to the fire of "throughput."

But there are exceptions. There are medical journalists who find settings in which they are encouraged to hone their skills and are rewarded for plying their trade brilliantly. There are not many such settings and not many such practitioners. I have been privileged to interact with and learn from several, including Shannon Brownlee. From the shelter of the New America Foundation, Brownlee turned her journalistic skills to the question, "Why can't the United States seem to fix its health care system?" Ten chapters later she concludes that "This is the sorry state of American health care. Doing what's best for patients is bad for business."

Many of these chapters reiterate arguments that are all too familiar and easily substantiated. The US health care system is inefficient in terms of any cost-benefit or risk-benefit measure. It is drowning in administration. It lacks uniformity in access, performance, and goals. It denigrates professionalism. Its infrastructure has become its master to such an extent that any attempt to care for and about patients is an insurmountable uphill battle.

Brownlee illuminates another flaw, one that has escaped general attention. Utilization of costly medical and surgical services is highly, often dramatically, variable from place to place—and the degree of utilization has no relationship to favorable outcomes. It follows that much of what is afforded to the patient is unnecessary. Furthermore, she argues that the driving force is the cash flow that is necessary to feed what has become a voracious, greedy monster.

This book is written for a sophisticated general audience. I hope it is widely read, providing patients with the needed resolve to stop demanding that their physicians prescribe the latest procedure, poultice, or potion that marketing or medical journalism foists on them. In turn, they should demand an answer to 2 queries: How certain are you that I will be truly advantaged by this option? And if you are certain you can make an important difference, how much more meaningful is the benefit of this option when compared with that of alternative approaches? Such queries seem counterintuitive in a nation that is deluded by declarations of medical prowess. Until this questioning becomes common sense, health care reform will remain an exercise in circular reasoning.

I came away from reading Overtreated far from satisfied with the format and the quality of the arguments. I have grappled with the relevant primary sources for decades and written extensively about medicalization and what I call type II medical malpractice (doing the unnecessary, even if you do it well). Brownlee's presentation is brilliant journalism but inadequate epistemology. Medical journalism is formulaic. Each of her chapters revolves around an engaging anecdote or two, usually a dramatic clinical event or an interview with a health service researcher whom Brownlee finds a convincing and particularly appealing personality. She then offers readers her take on these opinions, peppered with interesting extrapolations and entertaining allusions. If I could teach her to dissect the primary sources, she would not assert, "We can't improve the quality of health care or control costs without better evidence for what works and what doesn't. . . . " We already have the data to eliminate much that is "overtreatment." All we need to do is reign this in by demanding a meaningful degree of effectiveness before we are willing to underwrite any treatment.

By Nortin M. Hadler, MD