"Doctor, Is What You Are Doing Part of the 30% that is Waste?"

This column was originally published as a hard copy column in Alternative Medicine magazine.

I was recently part of a discussion breakout at an Institute of Medicine (IOM) meeting. Any reader of this column could have contributed to this exploration. Our job was to explore the patient and community roles in transforming care. Each participant, in part, assumed the role of the patients we sometimes are.

up to $1.5 trillion anually could be wasted

As talk turned to roles for empowered patients, I shared something I have done three times in recent years when consulting with specialists on an eye issue related to a basketball injury from 20 years ago. Treatment choices for my eye lie within a semi-elective grey-zone relative to potential surgery. My behavior as a patient, however, has been informed by my professional work-I wonder if all patients should use the same gambit.

Three years ago I came upon a 2008 editorial in the Journal of the American Medical Association called "From Waste to Value in Health Care." The authors stated that waste accounts for 30% to 50% of healthcare spending. What we know about such spending in a medical cascade that is ripe with adverse effects (read: morbidities and mortalities) is that much of that unnecessary spending is harmful to patients. A 2013 report from the IOM estimated waste at 30%.

Taking in the magnitude of this data point is one thing-between $1.0-trillion and $1.5-trillion a year wasted. The later is the United States' military budget, two times over. Think of how many schools, roads, teachers, retirements, and parks are dumped in the garbage. Think of the "opportunity costs" -- all the things we can't do because the medical industry is flourishing via overtreatment.

Report puts waste at 30%-50%

Personalizing this data point is tougher yet. Here is a rough analogy. A good baseball batter hits .300: three hits in 10 at-bats. The chance of such a player getting a hit is the same chance that wasteful medicine will be practiced on you.

The higher up the medical industry's economic food-chain into high-cost specialty practices you end up, the greater the risk. The meetings with my own series of ophthalmologists regarding a potential eye surgery inhabit this risky space: "Well, what we could do is ..." or "You need to see my colleague who is really one of the best ... "

Is the gorgeous, high-towered, and big-viewed office room in which one waits little more than a well-glossed sheen over the fact that you are actually sitting in a landfill?
 
This is not a comforting thought. Speaking like this also feels mean-spirited. Mainly, we like our doctors. I like the ophthalmologist I've consulted with for 20 years. I have taken a liking to most of the 5 others from whom I've recently sought additional perspectives or treatment following a geographic relocation and some aggravation in the eye.

Yet the fact glares back as bold as the big E on an eye chart: 30% -50% chance of waste on the care I receive.

Two May 2013 articles in the British Medical Journal won't make you feel any better. One is called "Influenza: Marketing vaccines by marketing disease." The author argues that campaigns to get everyone to take the influenza vaccination are based on trumped-up evidence and fear-mongering. Read: waste and potential harm.

The generalized practice of such marketing was the subject of an earlier piece entitled "A Call to Challenge the ‘Selling of Sickness.'" Medicine is characterized with snake oil and natural medicine salesmen on the back of Conestoga wagons: "unscrupulous," "dubious remedies," "out of control," "research suppressed and distorted for commercial gain," and worse. Then: "Patients experience well-documented harms as more and more financial imperatives are allowed to trump clinical judgment."

Berwick: his Triple Aim seeks to correct misaligned values

The editorial focused on an international meeting entitled "Call to Action on the Selling of Sickness." After noting that past campaigns have failed, the writers names new efforts underway to combat the practices. One is the exceptional "Choosing Wisely" campaign. Some medical specialties are working with Consumer Reports to first name then publicize over-performed procedures of their own discipline. This is an exceptional program.

The journal's own "Too much medicine campaign" is a second example. The "Triple Aim" effort in this country led by Donald Berwick, MD, is another effort. This campaign seeks to replace financial gain as the base of US medicine with values of: 1) patient experience, 2) population health and 3) lower costs.

These are not abstract public health issues. They are personal, and should deeply discomfort you, and me. Not just for the unfathomable opportunities lost to our public and private investment when $1-trillion plus a year goes down a drain. We each need to be concerned that what our trusted doctors suggest is, well, potentially damaging and unnecessary.

So when I sit down with a specialist to consider a recommended procedure or surgery, at a certain point I give them a chance to share my discomfort. I say: "From my work I've learned that the Institute of Medicine has concluded that 30%-50% of what is done in medicine is waste. They say that much of it is harmful. I have to assume that includes what happens inside these walls. Is your recommendation part of that 30%?"