The U.S. healthcare system, up my nostrils

If you'll bear with a brief personal medical narrative, I think it holds some lessons about overutlization and economic incentives in our healthcare system, though I'm not entirely sure what they are yet.

I've been plagued with nasal allergies all my life, and almost twenty years ago I also developed nasal polyps. The worst of the allergy symptoms moderated at about the same time, except when the polyps flared up, which would happen when I had a cold. On three separate occasions, I took steps to have the polyps removed surgically, which entailed taking the steroid spray Nasonex for a few weeks and the scheduling an operation. On each occasion I backed out of the operation. On each occasion, too, the Nasonex vastly improved my breathing, but I always went off it because I was under the impression it's bad to inhale a steroid indefinitely.

The last time I put this process in motion, in February 2012, I got some straight talk from the ENT doctor. Polyps and allergies require constant maintenance, he said. If I got the polyps removed, I'd have to stay on the steroid, and the polyps would likely grow back and have to be removed again. He convinced me that using Nasonex indefinitely would not be dangerous.

"Every time I go on Nasonex the polyps disappear," I said. "If I need to stay on the drug after I get the operation, what do I need the operation for?" He allowed that I had a point at wrote me a prescription refillable for a year.

Are doctors more "defensive" than studies show?

Aaron Carroll takes a whack at the alleged myth that medical tort reform has the potential to significantly reduce healthcare costs. Citing two studies published in the September 2010 issue of Health Affairs, he reports findings from the first that our medical liability system accounts for only an estimated 2.4% of total U.S. healthcare costs (a nontrivial $55.6 billion), and from the second that tort reform would reduce costs by a mere one tenth of one percent.

Carroll originally published this post as a guest blogger for Ezra Klein, who has often cited similar findings -- as did Obama, in the bipartisan healthcare summit he called in February 2010.  Personally, I am deeply suspicious of the Republican passion for tort reform, medical and otherwise, which is part and parcel of their aversion to holding any industry accountable for any damages it causes.  Nonetheless, claims that the medical liability system has only a modest effect of doctors' behavior always arouses my skepticism.  This skepticism comes in large part from listening to my wife, a nurse-midwife at an inner city hospital, who is forever frustrated by the obstetricians' hair-trigger for Caesarian sections. Her colleagues are plainly strung taut by the constant threat of lawsuits; whenever anything goes wrong everyone anticipates a suit. I strongly suspect that the threat of liability affects caregivers' behavior in ways that do not show up in the research.  And I have questions about both of the studies Carroll cites, and about Carroll's presentation of them.

First, the two studies are to a certain extent at cross-purposes.  Carroll as noted above, reports that the first study [purchase required], led by Michelle M. Mello in a team including Atul Gawande, pegs the cost of our "medical liability system" at 2.4% of total healthcare costs and finds that the vast majority of that cost comes from the practice of defensive medicine.  Carrol then notes that the second study, led by J. William Thomas, pegs the potential savings from tort reform at just .1% of total costs.  But in the Mello study, defensive medicine costs and tort reform savings are presented as one and the same thing. The authors estimate of total, system-wide costs is based entirely on a series of studies by Kessler and McClellan conducted from 1984--1994. All the results, and the Mello authors' extrapolations from them, use those two terms interchangeably (my emphasis):

Kessler and McClellan examined the effect of tort reforms that directly reduce expected malpractice awards—such as caps on noneconomic damages—on Medicare hospital spending for acute myocardial infarction and ischemic heart disease from 1984 to 1990.⁷ The reforms lowered hospital spending by 5.3 percent for myocardial infarction and 9.0 percent for heart disease....

A CT Scan foregone

Noting recent research indicating that many cancer screenings are of dubious value, Ezra Klein opines:

as long as doctors are telling scared and uncertain patients that they need to get screened, they’re getting screened. The moment they stop telling patients to get screened, screenings will plummet. In health care, doctors are really the relevant decision-makers. And right now, they don’t have the evidence to make good decisions nor the incentives to make cost-effective decisions.

That reminds me of a tale I heard told recently by a nurse midwife with many decades of experience working with doctors in hospitals -- and often tussling with them to forestall what she regards as unnecessary care, e.g., Caesarians.  She recalled a trip she took with her grandson to the emergency room after he fell out of a (stationary) truck bed, hitting his head on her driveway and getting a good-sized goose egg. She was deeply impressed with the exam that the ER physician conducted to rule out internal bleeding or risk of brain damage: her trained eye could appreciate how thorough it was. This doctor wanted  to avoid an MRI CT Scan* if all indicators were good, as they were.  That's quite unusual.