Unnecessary health care treatment is wasting billions of dollars, hurting patients and hamstringing the U.S. economy.

Shannon Brownlee, author of “Overtreated,” Dr. John Santa, director of the Consumer Reports Health Ratings Center, and Tim Bartholow, medical director for the Wisconsin Medical Society, shared what’s being done to counter overtreatment with an audience of nearly 300 employers, physicians, health system leaders, reporters and consumers at the Alliance Annual Seminar, “Overwhelmed by Overtreatment,” at the Monona Terrace on May 7, 2013.

‘Laying Waste’

Brownlee’s efforts to document the extent of overtreatment and the damage it causes have won national attention, including a featured interview in the award-winning documentary, “Escape Fire.” An award-winning journalist, Brownlee is senior vice president at the Lown Institute, which promotes health through research, education, training and global outreach.

“The inconvenient truth of health care is that we are simultaneously wasting billions of dollars on poor quality medical care and we are laying waste to our economy,” Brownlee said.

While health care is consuming more, it is delivering less in terms of good health based on measures such as infant mortality and rates of obesity and diabetes. Brownlee said one-third of health care does nothing to improve health: “It does not lengthen life, it does not ease suffering, it’s waste.” Overtreatment wastes approximately $800 billion a year.

Brownlee and other speakers noted that dealing with unnecessary care is different from rationing care. Rationing withholds care from people who would benefit from it, while countering overtreatment reduces waste in health care by eliminating unnecessary care that fails to benefit patients and sometimes causes harm to them.

Brownlee said physicians, nurses, and other members of the medical profession often feel trapped by a system “that makes it all too easy to deliver the wrong care and very hard to do what’s right.”

Addressing this problem will require multiple approaches created by “a multitude of people” working together, including employers, patients, employees, civic leaders, religious leaders, clinicians and government officials.

Ineffective Care

Unnecessary care involves treatments that are known to be ineffective or lack evidence that they are effective. Brownlee said only half of treatments currently used by physicians are backed by evidence proving they are effective.

Routine care also contributes to overtreatment. For example, Brownlee said hospital patients are given blood tests “and nobody even looks at the results.” Patients are given anticoagulants when hospitalized even though “It doesn’t do some of the patients any good and it does some of them harm.”

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EXECUTIVE SUMMARY

THE ALLIANCE ANNUAL SEMINAR: OVERWHELMED BY OVERTREATMENT

MAY 7, 2013

ESCAPE FIRE

Brownlee and other health care leaders are featured in “Escape Fire,” the award-winning documentary on the broken U.S. health care system. View the trailer at: www.escapefiremovie.com/trailer.

Brownlee cited evidence that one in three imaging tests such as computed tomography (CT) scans is unnecessary. Yet CT scans expose patients to high levels of radiation, which causes cancer. A single CT scan delivers radiation equal to 350 chest X-rays.

Some procedures have even higher levels of overuse: Brownlee said 70 percent of carotid endarterectomy surgeries on the carotid artery in the neck are done on people who will not benefit from them. The procedure is done to prevent stroke.

“Even more important to me is the harm that overuse causes,” Brownlee said. Every year, 30,000 Medicare beneficiaries die due to overtreatment, which is extrapolated to 200,000 unnecessary deaths a year among all Americans.

Examining Variations

Regional variations in the use of some procedures can indicate overtreatment. Wisconsin and Illinois each have a tenfold variation among health care regions in the usage of percutaneous coronary intervention (PCI) procedures. PCI includes angioplasty to open clogged heart arteries and the insertion of a stent — a tiny mesh tube — to help keep them open.

“The places that have the most PCIs do not correspond with patients who have the most heart disease,” Brownlee said. They also do not correspond to the population’s age or other factors. PCIs can save people during a heart attack, but most are done solely to treat chest pain and shortness of breath. Yet 88 percent of patients thought having PCI would reduce the risk of a heart attack and 70 percent thought it would reduce the risk of dying. Neither are true.

Brownlee said at least 15 percent of PCIs are performed on inappropriate or questionable patients who are “more likely to be harmed than helped.” More than 1,000 patients who receive an unnecessary PCI annually die as a result. Brownlee said Dr. Bernard Lown, who invented the cardiac defibrillator and is a Nobel laureate, believes more than half of PCIs are unnecessary.

“What this means is there are tens of thousands of Americans walking around with little mesh tubes in their hearts that are unnecessary,” Brownlee said.

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Root Causes of Overtreatment › Faith-based medicine: 50 percent is

non-evidence-based.

› Poor post-market surveillance: Medicine does not track the devices it puts in patients, for example.

› Defensive medicine: Doctors perform some tests or treatments due to fear of being sued.

› Fee for service: The current medical system rewards volume rather than value.

› Inefficiency: Delivery processes are often chaotic.

› Excess capacity: Hospitals have too many beds and specialists, with not enough primary care physicians. More beds typically mean more care.

› Outdated social contract: Doctors are expected to police themselves and purchasers too often pay for whatever is charged.

Source: Shannon Brownlee

Sources of Unnecessary Care

Category Example

Ineffective treatments & tests Antibiotics for viral infection

Inappropriately used treatment & tests CT scan with no evidence of intracranial trauma on a neurological exam

Non-evidence based treatments or tests Hospitalization for chronic illness

Routine but useless tests and procedures Routine anticoagulant for all hospitalized patients

Futile rescue care Ventilation or feeding tube for an elderly patient suffering multiple organ failure or advanced dementia

Unwanted elective procedures & tests Elective surgeries

Unwanted end-of-life care Prolonged death

Source: Shannon Brownlee

Ineffective Care, continued:

A Cultural Issue

Physicians may blame overtreatment on the threat of being sued, yet that explains only a portion of the problem. Another factor is patient demand rooted in Americans’ belief that more health care is better; high tech health care is better than low tech health care; drugs and treatments will improve life; and treatments can help them “cheat death.”

The varied factors that lead to overtreatment show that the problem is rooted in the organizing, financing and culture of American health care. While the problem impacts all Americans, Brownlee said it may do the greatest harm to the elderly.

Brownlee shared data showing elderly patients nearing the end of their life who live in Milwaukee spend significantly more time in the intensive care unit (ICU), visit more doctors and spend more Medicare dollars than patients at the low end of the usage spectrum in LaCrosse.

“I don’t understand how dying patients in Milwaukee are sicker than dying patients in LaCrosse,” Brownlee dryly remarked. The difference reflects the “wickedly complex” nature of overtreatment. Addressing the problem will require multiple solutions, including:

› Shared decision-making, which helps physicians talk with patients to help them visualize the risks and benefits of tests and treatments.

› Decision aids, which help doctors make appropriate decisions about tests and treatments by presenting information at the time they are ordered.

› Choosing Wisely, a set of education materials produced by Consumer Reports to improve the interaction between physicians and patients.

Changing the “social contract” between the health care system and American citizens is essential. Americans must understand how the fee-for-service system works, how overcapacity increases overtreatment, and how their attitudes influence overtreatment. Wisconsin is a leader in examining these issues, which means it is in a position to help the country understand what the issues are and how to address them. It is essential that the discussion begins now, Brownlee said.

“To change health care, we the people must rethink what we are getting from health care and what it is we really want.”

Choosing Wisely

Santa said Consumer Reports’ Choosing Wisely campaign has been “incredibly successful” in promoting better interactions between patients and physicians, but there is more to be done.

Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients have meaningful conversations about the overuse of tests and procedures. The effort was inspired by an article by Dr. Howard Brody, who suggested that physicians create a “top five list” to identify procedures that are the “most egregious causes of waste.”

To date, 41 physician specialty societies have signed up to develop “top five” messages, which Consumer Reports then turns into patient-friendly materials for consumers. Tools and messages are available online at www.consumerhealthchoices.org.

Materials are distributed by specialty societies, consumer organizations, the ABIM Foundation, Consumer Reports and its partners, including The Alliance. The Illinois-based Midwest Business Group on Health has promoted Choosing Wisely with a special website, a television spot on the importance of physician-patient partnerships and a new project aimed at helping pregnant women avoid early elective deliveries. Major media outlets have joined the Choosing Wisely effort with articles and interviews.

“This has turned into an industry and cultural phenomenon,” Santa said.

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PO Box 44365 | Madison WI 53744-4365 | 800.223.4139 | 608.276.6620 p | 608.276.6626 f | www.the-alliance.org

“We can’t let this moment slip away. Too much depends on what has to happen now.”

— Shannon Brownlee

‘What Not To Do’

Choosing Wisely focuses on telling people “what not to do” to help them avoid overtreatment, Santa said. Yet consumers are “very wary” about overtreatment messages. Five approaches work well to overcome consumers’ wariness:

1. Go where the people are. Choosing Wisely shares information on web sites such as Wikipedia and media outlets such as Vogue, for example.

2. Talk about what people are talking about and connect your dots to theirs with engaging topics. People are willing to talk about benefits, for example, and can connect the dots with issues such as risk and waste.

3. Use safety if you can. Patient safety messages help overcome our “more is better” tendencies as a society.

4. Use empathic stories. Stories about real experiences resonate with readers.

5. Provide a structure for decision-making. Telling consumers what not to do “breaks” the expected pattern so plan to “fix it” with another structure for making decisions.

These rules were applied in Consumer Reports’ March article on “Three Cancer Tests You Need Plus Three You Don’t.” The article, which drew the highest number of readers in the magazine’s history, included the empathic story of a physician who almost died after a Prostate-Specific Antigen (PSA) test for prostate cancer.

A new set of materials is now available in Phase 2 of the Choosing Wisely campaign, ranging from webinars and employer toolkits to videos and posters for physician offices.

Starting A Movement

Santa said Choosing Wisely is helping Consumer Reports “soften the battlefield” for changing the culture of modern medicine.

“We’re fighting a culture war to try to get people to change their minds,” Santa said. “More is not better.”

Changing culture will require a social movement combining the efforts of many different organizations and individuals to create social change. At the local level, three steps can help employers make a difference.

1. Find local consumer partners and listen to their advice for reaching patients.

2. Let a “different group” of physicians take the lead. Work with physicians who are willing to work toward more primary care and more accountability and then be willing to channel more rewards to top performers.

3. Encourage the use of “open notes” so patients can read them.

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PO Box 44365 | Madison WI 53744-4365 | 800.223.4139 | 608.276.6620 p | 608.276.6626 f | www.the-alliance.org

Choosing WiselyWisconsin Grant

The Wisconsin Collaborative for Healthcare Quality (WCHQ) won one of 21 Choosing Wisely grants to regional collaboratives.

WCHQ will work with health systems, medical groups, hospitals and health plans from April 2013 through March 2015 to:

› Educate physicians about opportunities to reduce waste and overuse.

› Build physician communication skills so they can have conversations with patients about the care they need.

› Participate in a grantee learning cooperative to share best practices and enhance effectiveness.

“These are robust topics about big things that can make a huge difference to us.”

— Dr. John Santa

Wisconsin Efforts

Bartholow said it is important to remember that overtreatment is harmful to patients. It is also poor stewardship, which means some people who could benefit from care lack access to it.

Wisconsin physicians’ efforts to address overtreatment include the work of specialty group teams for cardiology and orthopedics. Physicians examined the impact of physician behavior on overtreatment and the use of health resources.

Bartholow said physicians can use four tenets to guide their efforts to address overuse:

1. Assure that health is optimized by keeping people well.

2. When the individual is not well, choose wisely when selecting diagnostic or treatment approaches by testing for appropriateness.

3. When appropriate, reduce variations.

4. Share decisions with patients.

An aging population and poor personal accountability for health are “economic realities” that add urgency to the discussion. It’s important for doctors to have access to the best advice and best decision tools at the bedside to address significant, costly events.

For example, the RadPort tool can pop up when physicians are ordering imaging to help physicians and doctors engage in shared decision-making about tests. RadPort uses American College of Radiology criteria to compare an individual physician’s practices to guidelines and then offer alternatives. Physicians in Minnesota used Radport to “bend the trend” of cost increases.

SMARTCare

Other Wisconsin projects include SMARTCare, which cardiologists are using to spur discussions with patients about cardiac catheterization. As part of the process, the physician compares his or her performance to benchmarks and appropriate use criteria for both local partners and physicians statewide.

I-PrACTise tapped Wisconsin’s strength in industrial engineering by drawing together a group of physicians and industrial engineers for a two-day meeting to review the information required by care teams and consider how physicians can reserve time for decision-making.

Bartholow noted that purchasers and patients must participate in efforts to reduce overtreatment. Employers and other purchasers should aim to purchase higher-quality health care, including the use of steerage programs that create incentives for employees to use high-quality providers.

“Purchasers can help us chart this North Star course,” Bartholow said. “If they don’t, we as a society will not receive the care that we think is deserved by our parents, our children and ourselves.”

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PO Box 44365 | Madison WI 53744-4365 | 800.223.4139 | 608.276.6620 p | 608.276.6626 f | www.the-alliance.org

“The conversation has begun about how many resources it takes to get to high-quality care.”

— Dr. Tim Bartholow

The Alliance moves health care forward by controlling costs, improving quality, and engaging individuals in their health. An employer-owned, not-for-profit cooperative, our 180 members provide coverage to more than 80,000 individuals in Wisconsin, Illinois, and Iowa.