That title is a little cheeky, I know. The perils of requiring serious medical care without insurance are well documented. But in his new book, “Overdiagnosed,” Dr. H. Gilbert Welch and his colleagues, Drs. Lisa Schwartz and Steven Woloshin, chronicle some of the perils of too much medical care. (All three authors are professors at The Dartmouth Institute for Health Policy and Clinical Practice.) In particular, the problems with the ever-burgeoning body of diagnostic tests that lead to unnecessary treatments that end up making people sicker than they ever would have been had the test not alerted a doctor to a potential problem. (Welch never suggests that people shouldn’t have insurance — although he does mention in passing how this is one area where not having insurance is actually a benefit.)
This post is not a review – I’m late to the party, and you can read reviews of his book, Q&As and excerpts here and here and here and here. But because this juicy, fact-filled book is so, well, juicy and fact-filled, I thought I’d post a few choice insights. Here we go:
“Overdiagnosed” looks at the many routes that lead to unnecessary care. One of these is changing the rules – the guidelines for what qualifies someone as having hypertension or dangerous blood sugar levels get changed and overnight, millions of people become patients. For example, changing the threshold for abnormal total cholesterol from greater than 240 to greater than 200 meant an additional 42 million people in the United States qualified as having high cholesterol. But as Welch writes, “a cholesterol of 200 is almost right in the middle—just above average for the U.S. adult population.” Changing the osteoporosis-indicating T score, a measure of bone density, from 2.5 to 2.0 led to an 85% increase in the number of women with osteoporosis (over 6 million new cases). Welch points out that there are plenty of conflicts of interest when it comes to changing the rules for what qualifies as a pre-disease state of affairs. Many of the boards and organizations that are behind these decisions are stocked with industry professionals or others who stand to benefit (ie, make money) from the millions of new prescriptions that they are about to spur. (That’s not to say all of these changes are guided by profit. They aren’t.)
Improvements in imaging technology have also led to overdiagnosis. About 10% of people without any symptoms of gallbladder disease have gallstones when scanned by ultrasound. About 40% of people without knee pain or a history of knee injury have meniscal damage in their knees when scanned by an MRI. One radiologist told Welch, “The realities are, with this level of information, I have yet to see a normal patient.” In Pennsylvania, the number of people diagnosed with pulmonary embolism increased 34% in less than 5 years because of increased use of computed tomography scanning.
Then there is the prostate cancer question. Welch spoke about this at length during an NPR interview that you can listen to or read online.
The book goes on and on – the ramifications of looking harder for breast cancer, of mistaking DNA for disease, and of finding what he calls “incidentalomas.”
But the story gets interesting all over again when it turns to looking at what can be done. Welch points out the problem with the fact that patients are insulated from the full price of a service. In the overlapping roles of being a patient and being a consumer, things get murky. How is the buyer (ie, patient) supposed to evaluate the value of the goods being sold? How is a patient supposed to assess whether the product is worth the price when (a) we don’t know the price and (b) the value of the product can’t be determined until a couple of decades in the future? Welch says that in medicine, the sellers are in an ideal position because they, not the buyer, create the demand for their product. Here’s the excerpt:
“To be fair, the ability to create demand is not unique to medicine—the service department at my local Volvo dealer is fairly adept at it as well. But the problem is exacerbated in medicine because of the combined effect of the aforementioned factors: buyers’ not paying the full price (or even knowing it); their having little idea about what medical care they need (or the benefits they can reasonably expect); and their being poorly positioned to think about options. … People can’t feel better after treatment when they weren’t experiencing any symptoms to begin with. And no one can feel a change in the risk of having a bad outcome.”
This snapshot isn’t comprehensive – there’s much more to find within these pages. And though many of the territories mentioned are already well trodden—such as the fact that the quickest way to expand a market for a drug is to expand the definitions for the treated disease—this book has the kind of meaty research that helps give weight to our own decisions regarding health and medicine.
And although it seems sacrilegious to even raise the idea that sometimes not having health insurance could be a good thing (as someone who has health insurance, who am I to even suggest it?) you kind of have to wonder. Between the potential level of overdiagnosis taking place and the high prices of drugs, what would healthcare be like if there were no insurance at all? Are people who have insurance more likely to get these tests and prescriptions than people without insurance? Would there be barely any care at all? Or would it all make much more sense than it does today? Maybe we would have a healthcare bill that was less than ten pages long, for example. Welch points out that the problem with overdiagnosis is that people who are not sick and who are unlikely to become sick are getting treated with preventive medications that end up causing problems of their own. Without insurance, we would be much more aware of the costs of these tests and perhaps be less likely to obtain them. The point is tangential to the phenomenon of overdiagnosis, but it’s hard not to wonder what this particular phenomenon would look like in the absence of insurance.
After all, as Welch writes, “we all have to wonder about the paradox of promoting health by encouraging policies that lead more people to view themselves as sick.”