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So much costly unneeded care it hurts

Mammograms showing a normal breast (left) and a breast with cancer (right, white arrows).


F0r Kaiser Health News

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

“You’re terrified out of your mind” after a diagnosis of cancer, said Dennison, 55, a retired psychologist from Orange County, Calif.

In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea that there was another option.

Medical research published in The New England Journal of Medicine in 2010 — six years before her diagnosis — showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.

In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison — who was over 50, with a small cancer that hadn’t spread — without considering the shorter therapy.

“It’s disturbing to think that I might have been overtreated,” Dennison said. “I would like to make sure that other women and men know this is an option.”

Dennison’s oncologist, Dr. David Khan of El Segundo, Calif., notes that there are good reasons to prescribe a longer course of radiation for some women.

Khan, an assistant clinical professor at UCLA, said he was worried that the shorter course of radiation would increase the risk of side effects, given that Dennison had undergone chemotherapy as part of her breast cancer treatment. The latest radiation guidelines, issued in 2011, don’t include patients who’ve had chemo.

Yet many patients still aren’t told about their choices.).

An exclusive analysis for Kaiser Health News found that only 48 percent of eligible breast-cancer patients today get the shorter regimen, in spite of the additional costs and inconvenience of the longer type.

The analysis was completed by eviCore healthcare, a South Carolina-based medical-benefit-management company, which analyzed records of 4,225 breast-cancer patients treated in the first half of 2017. The women were covered by several commercial insurers. All were over age 50 with early-stage disease.

The data “reflect how hard it is to change practice,” said Dr. Justin Bekelman,  associate professor of radiation oncology at the University of Pennsylvania Perelman School of Medicine.

A growing number of patients and doctors are concerned about overtreatment, which is rampant across the health care system, argues Dr. Martin Makary,  a professor of surgery and health policy at the Johns Hopkins University School of Medicine, in Baltimore.

From duplicate blood tests to unnecessary knee replacements, millions of patients are being bombarded with screenings, scans and treatments that offer little or no benefit, Makary said. Doctors estimated that 21 percent of medical care is unnecessary, according to a survey that Makary published in September in Plos One.

Unnecessary medical services cost the health care system at least $210 billion a year, according to a 2009 report by the National Academy of Medicine, a prestigious science advisory group.

Those procedures aren’t only expensive. Some clearly harm patients.

Overzealous screening for cancers of the thyroid, prostate, breast and skin, for example, leads many older people to undergo treatments unlikely to extend their lives, but which can cause needless pain and suffering, said Dr. Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice.

“It’s just bad care,” said Dr. Rebecca Smith-Bindman, a professor at the University of California-San Francisco, whose research has highlighted the risk of radiation from unnecessary CT scans and other imaging.


Annie Dennison said doctors offered just one option after her breast-cancer diagnosis last year: six weeks of radiation treatment.

Outdated Treatments

All eligible breast-cancer patients should be offered a shorter course of radiation, said Dr. Benjamin Smith,  an associate professor of radiation oncology at the University of Texas MD Anderson Cancer Center.

Studies show that side effects from the shorter regimen are the same or even milder than traditional therapy, Smith said.

“Any center that offers antiquated, longer courses of radiation can offer these shorter courses,” said Smith, lead author of the radiation oncology society’s 2011 guidelines.

Smith, who is currently updating the expert guidelines, said there’s no evidence that women who’ve had chemo have more side effects if they undergo the condensed radiation course.

“There is no evidence in the literature to suggest that patients who receive chemotherapy will have a better outcome if they receive six weeks of radiation,” Smith said.

Shorter courses save money, too. Bekelman’s 2014 study in JAMA, the journal of the American Medical Association, found that women given the longer regimen faced nearly $2,900 more in medical costs in the year after diagnosis.

The high rate of overtreatment in breast cancer is “shocking and appalling and unacceptable,” said Karuna Jaggar, executive director of Breast Cancer Action, a San Francisco-based advocacy group. “It’s an example of how our profit-driven health system puts financial interests above women’s health and well-being.”

Just getting to the hospital for treatment imposes a burden on many women, especially those in rural areas, Jaggar said. Rural breast cancer patients are more likely than urban women to choose a mastectomy, which removes the entire breast but typically doesn’t require follow-up radiation.

Too Many Tests

Meg Reeves, 60, believes much of her treatment for early breast cancer in 2009 was unnecessary. Looking back, she feels as if she was treated “with a sledgehammer.”

At the time, Reeves lived in a small town in Wisconsin and had to travel 30 miles each way for radiation therapy. After she completed her course of treatment, doctors monitored her for eight years with a battery of annual blood tests and MRIs. The blood tests include screenings for tumor markers, which aim to detect relapses before they cause symptoms.

Yet cancer specialists have repeatedly rejected these kinds of expensive blood tests and advanced imaging since 1997.

For survivors of early breast cancer such as Reeves — who had no signs of symptoms of relapse — “these tests aren’t helpful and can be hurtful,” said  Dr. Gary Lyman,  a breast-cancer oncologist and health economist at the Fred Hutchinson Cancer Research Center. Reeves’ primary doctor declined to comment.

In 2012, the American Society for Clinical Oncology, the leading medical group for cancer specialists, explicitly told doctors not to order the tumor marker tests and advanced imaging — such as CT, PET and bone scans — for survivors of early-stage breast cancer.

Yet these tests remain common.

Thirty-seven percent of breast cancer survivors underwent screening for tumor markers between 2007 and 2015, according to a study presented in June at the American Society of Clinical Oncology’s annual meeting and published in the society’s journal online.

Sixteen percent of these survivors underwent advanced imaging. None of these women had symptoms of a recurrence, such as a breast lump, Lyman said.

Beyond wasted time and worry for women, these scans also expose them to unnecessary radiation, a known carcinogen, Lyman said. A National Cancer Institute study estimated that 2 percent of all cancers in the United States could be caused by medical imaging.

Paying The Price

Health care costs per breast-cancer patients monitored with advanced imaging averaged nearly $30,000 in the year after treatment ended. That was about $11,600 more than for women who didn’t get such follow-up tests, according to Lyman’s study. Women monitored with biomarkers had nearly $6,000 in additional health costs.

Reeves knows the costs of cancer treatment all too well. Although she had health insurance from her employer, she says she had to sell her house to pay her medical bills. “It was financially devastating,” Reeves said.

“It’s the worst kind of financial toxicity, because you’re incurring costs for something with no benefit,” said Dr. Scott Ramsey,  director of the Hutchinson Institute for Cancer Outcomes Research.

Even simple blood tests take a toll, Reeves said.

Repeated needle sticks — including those from unnecessary annual blood tests — have scarred the veins in her left arm, the only one from which nurses can draw blood, she says. Nurses avoid drawing blood on her right side — the side of her breast surgery — because it could injure that arm, increasing the risk of a complication called lymphedema, which causes painful arm swelling.

Reeves worries about the side effects of so many scans.

After treatment ended, her doctor also screened her with yearly MRI scans using a dye called gadolinium. The Food and Drug Administration is investigating the safety of the dye, which leaves metal deposits in organs such as the brain. After suffering so much during cancer treatment, she doesn’t want any more bad news about her health.

Becoming An Advocate

Kathi Kolb, 63, was staring at 35 radiation treatments over seven weeks in 2008 for her early breast cancer. But she was determined to educate herself and find another option.

“I had bills to pay, no trust fund, no partner with a big salary,” said Kolb, a physical therapist from South Kingstown, R.I. “I needed to get back to work as soon as I could.”

Kolb asked her doctor about a 2008 Canadian study, which was later published in the influential New England Journal of Medicine, showing that three weeks of radiation was safe. He agreed to try it.


Kolb, a Rhode Island physical therapist, says she’s frustrated that fewer than half of eligible breast cancer patients receive a shorter course of radiation, even though studies proved it was safe nearly 10 years ago. (Katye Martens Brier for KHN)

Even the short course left her with painful skin burns, blisters, swelling, respiratory infections and fatigue. She fears these symptoms would have been twice as bad if she had been subjected to the full seven weeks.

“I saved myself another month of torture and being out of work,” Kolb said. “By the time I started to feel the effects of being zapped [day] after day, I was almost done.”

A growing number of medical and consumer groups are working to educate patients, so they can become their own advocates.

The Choosing Wisely campaign, launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation, aims to raise awareness about overtreatment. The effort, which has been joined by 80 medical societies, has listed 500 practices to avoid. It advises doctors not to provide more radiation for cancer than necessary, and to avoid screening for tumor markers after early breast cancer.

“Patients used to feel like ‘more is better,’” said Daniel Wolfson, executive vice president of the ABIM Foundation. “But sometimes less is more. Changing that mindset is a major victory.”

Yet Wolfson acknowledges that simply highlighting the problem isn’t enough.

Many doctors cling to outdated practices out of habit, said Dr. Bruce Landon, a professor of healthcare policy at Harvard Medical School.



“We tend in the health care system to be pretty slow in abandoning technology,” Landon said. “People say, ‘I’ve always treated it this way throughout my career. Why should I stop now?’”

Many doctors say they feel pressured to order unnecessary tests out of fear of being sued for doing too little. Others say patients demand the services. In surveys, some doctors blame overtreatment on financial incentives that reward physicians and hospitals for doing more.

Because insurers pay doctors for each radiation session, for example, those who prescribe longer treatments earn more money, said Dr. Peter Bach, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes in New York.

“Reimbursement drives everything,” said economist Jean Mitchell, a professor at Georgetown University’s McCourt School of Public Policy. “It drives the whole health care system.”

Smith-Bindman, the UC-San Francisco professor, said the causes of overtreatment aren’t so simple. The use of expensive imaging tests also has increased in managed care organizations in which doctors don’t profit from ordering tests, her research shows.

“I don’t think it’s money,” Smith-Bindman said. “I think we have a really poor system in place to make sure people get care that they’re supposed to be getting. The system is broken in a whole lot of places.”

Dennison said she hopes to educate friends and others in the breast cancer community about new treatment options and encourage them to speak up. She said, “Patients need to be able to say ‘I’d like to do it this way because it’s my body.’”


Looking at the link of payer type and low-value care

Researchers from The Dartmouth Institute for Health Policy and Clinical Practice examined the connection between payer type and low-value care to determine what effect that insurance design (commercial insurance vs. Medicare) may have on medical overuse and waste.

Among their findings:

  • “The tendency to deliver or avoid low-value care appears largely independent of payer type (Medicare or commercial) and patient population attributes. (Researchers note that the finding suggests that either the difference in anticipated reimbursement is unimportant to providers or that they are ‘unwilling or unable to discriminate by payer type at the point of care.’)
  • “Regions with a high specialist to primary care ratio have more overuse.
  • “Some Hospital Referral Regions may deliver more overuse either as a direct result of higher physician group competition or as an indirect result (more competition results in more fragmentation and redundancy).
  • “The use of the seven low-value services remained relatively consistent over time. However, Vitamin D screening increased substantially during the study period (perhaps as a result of increased public awareness and the promotion of Vitamin D deficiency as a medical concern). In contrast, the use of cervical cancer screening in the over 65 population decreased substantially.
  • “The rate of prescription of opioids for migraine patients is similar in both commercially insured and Medicare populations, but is much more commonly provided than the other Choosing Wisely services examined in the study. (The study’s authors note that study data may not reflect the slight decline in prescription opioid use in response to growing concerns over opioid abuse.)
  • “Finally, the study found that the use of low-value services in both payer types was greater among {groups with} higher proportions of black patients. The researchers note that their finding suggests a concerning ‘potential for double jeopardy in health services receipt among black Americans.’”

To read more, please hit this link.


Choosing Wisely, Consumer Reports team up



The “Choosing Wisely” initiative of the American Board of Internal Medicine (ABIM) Foundation has asked more than 70 medical societies, associations and other  groups to list common medical tests/procedures that are often clinically unnecessary and that can even cause harm in some cases.

To promote its mission of reducing unneeded medical activity, Choosing Wisely has  now partnered with Consumer Reports to create a Web site as well as videos and downloadable materials for patients and providers covering most of the Choosing Wisely recommendations. They have also have launched an iOS app for patients for easy access to these materials on the go. The app includes drugs as well as tests and procedures.

Hit this link to get to the new Consumer Reports/Choosing Wisely Web site.

Hit this link to get to the Choosing Wisely Web site.

Hit this link to read a Med Page Today article on this topic.


Trying to define and reduce low-value care


A  new Health Affairs article is based on discussions with 13 experts on how to reduce  low-value care.  Little consensus was found.

The authors noted: “Solutions to measure, identify, and eliminate low-value care … are challenging and complex. To date, most efforts aimed at reducing low-value care, such as the Choosing Wisely Initiative, have been limited to areas where there is high degree of consensus that the care rendered is low value.”

The authors said they focused on “overuse/overtreatment, failures of care delivery and coordination, and pricing failures. We proposed working definitions of low-value care and explored how participants considered defining and measuring low-value care.”

Findings include:

  • “There is a healthy skepticism of consensus methods, such as Choosing Wisely, in identifying low-value care beyond obvious ‘low-hanging fruit.’ There was not clear consensus on how to use components such as patient preferences, health-related quality of life, or competing risks and risk-benefit tradeoffs (e.g., at what age to initiate and terminate certain preventive screenings) to define and measure low-value care.
  • “There was little consensus on the validity, practical application, and priority for using cost-effectiveness analysis to inform coverage and pricing decisions.”
  • “Although there was agreement that price and cost should be included, particularly unjustified price variation, (e.g., price at freestanding versus facility-adjoined surgical or infusion therapy center) in efforts to reduce low-value care, there was not clear agreement on how that should be done.”

Still, the interviewees agreed  on elements of low-value care that need immediate attention. Among them: medical errors and pricing failures.

The writers proposed the following actions:

  • Looking into incorporating “Choosing Wisely, USPTF, and similar lists into performance and quality measurement for alternative payment programs.”
  • Expanding current low-value care lists “beyond nearly universal low-value care to include items where value is circumstance-dependent. Given concerns about limiting access to appropriate care, we recommend a tiered approach that takes into account both the magnitude and certainty of low-value care use. This effort would need to incorporate patient protections.”

T0 read the article, please hit this link.

Why U.S. can’t control healthcare costs


Ryan Gamlin, a former healthcare-management consultant and currently a medical student at the University of Cincinnati, has written a very useful and insightful commentary  in Medical Economics on  why the U.S. can’t control healthcare costs and has mediocre outcomes compared to other developed democracies.

He concludes:

“New reimbursement structures, like shared savings and ACOs, will draw provider and payer incentives closer to one another – and it is within these highly aligned arrangements that the efforts of physician stewardship organizations, such as Costs of Care and Choosing Wisely, will likely be most effective.

“But with 53% of physician reimbursement  {still} tied to fee-for-service, the majority of dollars saved through these efforts are still subject to recapture by insurers, administrators, or other entities, rather than making their way back to patients in the form of lower out-of-pocket costs.

“As Holman W. Jenkins  {of The Wall Street Journal} pointed out in a recent, devastating satire of the  Epi-Pen scandal, many of the incentives in the current healthcare system are aligned only with growing the total scale of healthcare expenditures, not shrinking them.

“Until we create a system that rewards investment in wellness and healthcare dollars not spent, there is reason to fear that the negative effects of healthcare excesses will continue to be borne by households, businesses, and governments.”

To read his whole piece, please hit this link.


Making Choosing Wisely efforts work

This article looks at the importance of physicians’ communication skills in reaching the goals of the Choosing Wisely campaign, which is aimed at resisting the push for medical interventions not backed by strong evidence.

This is a good look at communications strategies that might work.

‘Choosing Wisely’ may not win some malpractice suits


18th Century Statute of Lady Justice, at Castellania,  Italy. Her sword signifies the coercive power of a court,  her scales represent an objective standard by which competing claims are weighed, and her blindfold indicates that justice should be impartial and meted out objectively without fear or favor.

William Sullivan, D.O., and also a lawyer, discusses why “Choosing Wisely” won’t necessarily protect providers from malpractice suits.

He concludes:

“{Treatment} guidelines are created for many purposes. The intent of a guideline significantly affects whether the guideline will protect a physician against medical malpractice risk. Guidelines relating to payment issues should not be used for clinical or medicolegal purposes without strong clinical research supporting their conclusions. While clinical practice guidelines may be useful for both clinical and medicolegal purposes, the recommendations should be compared with current medical literature to determine whether the guidelines constitute appropriate medical care.

“Statutory guidelines and safe harbors significantly reduce a practitioner’s malpractice risk and also provide a strong deterrent to frivolous lawsuits. However, the decreased risk must be weighed against the inference of negligence that occurs if a statutory guideline is not followed, and against the potential transition of medical practice from a healing art to an exercise in checking all of the appropriate boxes to avoid liability.”

Review of the ‘Choosing Wisely’ campaign


Here’s a review of the  successes and disappointments so far of the ABIM  Foundation’s “Choosing Wisely” campaign aimed at getting patients and clinicians to talk more thoroughly and honestly  with each other about medical, financial, psychological and other issues that should be addressed in healthcare decision-making. The aim is better care and tighter cost control.

It’s by Daniel Wolfson, M.D., of the ABIM Foundation, which is part of the American Board of Internal Medicine empire.

His remarks in a long HealthAffairs piece include:

Choosing Wisely has been criticized for focusing on conversations instead of measures and implementation. It has also been criticized by some who said the content of the lists of unnecessary tests and procedures compiled by various specialties do not address more challenging areas of overuse. These are valid concerns.”


“Efforts to develop additional lists of wasteful tests and procedures are already happening at the grassroots level, such as the Journal of Hospital Medicine’s new series: Choosing Wisely: Things we do for no reason. Group practices have also begun these conversations. We welcome more and more communities to work together to discuss what unnecessary tests and procedures they may be ordering and performing.”



Study: ABIM’s Choosing Wisely campaign disappointing so far



The American Board of Internal Medicine’s Choosing Wisely campaign aimed at reducing the incidence of unneeded and sometimes clinically dangerous care has not had much of an impact so far.

A study  in JAMA Internal Medicine found that, for seven treatment and testing services listed by the Choosing Wisely campaign as usually unnecessary, use of only two had declined, but use of the other five either didn’t change or increased.

A  possible caveat:  All the investigators in the study are affiliated with Anthem, the big health insurer, and led by Alan Rosenberg, M.D., the firm’s vice president for clinical pharmacy and medical policy .

The researchers recommended new measures to  achieve substantial  change in physician knowledge and behavior.

Many, though not all, of the services covered by Choosing Wisely are related to diagnostic imaging.

The study said:  “The relatively small use changes suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice. Some of the additional interventions needed include data feedback, physician communication training, systems interventions (e.g., clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies, and financial incentives.”

‘Choosing Wisely’ in the Alps


Herewith an article on the Swiss version of the American Board of Internal Medicine’s “Choosing Wisely” program to reduce the number of treatments that evidence-based medicine suggests are unneeded or worse and by so doing control costs.

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