Overdosed America by Dr. John Abramson

Author:Dr. John Abramson
Language: eng
Format: epub
Publisher: HarperCollins

SUPPLY-SENSITIVE MEDICAL SERVICES

The term “supply-sensitive care” is applied to the kinds of medical services that are most vulnerable to getting pushed into use by the providers’ financial interests rather than pulled into service by the health needs of the surrounding community. Without a formal mechanism of health technology assessment, new medical services can be brought into use without strong scientific evidence of benefit. And without limits on spending, new services can be brought into use without evidence that they provide more health value than the services they would be replacing. The absence of both of these constraints on the growth of medical technology allows the U.S. health care system to be uniquely shaped by financial incentives.

Four features are shared by the medical services that are most vulnerable to overuse because of this supply-side push.

First, supply-sensitive services must be covered by insurance. When insurance coverage shields patients from the real cost of their care, they are unlikely to question whether the health value of a test or procedure justifies its cost. If, for example, heart attack patients had to pay the extra $10,000 that American-style invasive post–heart attack care now costs, many would demand access to the kind of information presented above. My guess is that most patients with uncomplicated heart attacks, when presented with the best available evidence, would conclude that the likelihood of benefit from invasive cardiac testing and procedures is not great enough to justify the increased risk and cost, and they would opt for more conservative care. I also suspect that if the technological razzamatazz were no longer such a distraction, the kinds of commonsense interventions that lead to better health outcomes for most people would then move into the foreground, where they belong.

Second, supply-sensitive services must appear on the surface to be beneficial, preempting the need for proof. How many women with advanced breast cancer, facing a poor prognosis, would turn down the opportunity to have a bone marrow transplant when the prevailing attitude is “It’s your only chance”? How many heart attack patients would require de-tailed proof of the benefit when their cardiologist says, “We should do a cardiac catheterization to make sure that none of your coronary arteries is about to become completely blocked and cause more damage to your heart”? How many new mothers would say no if their baby’s doctor recommended transfer to the intensive care nursery?

Third, the need for supply-sensitive services must be determined by the doctors who perform the service. Even though doctors almost universally believe that their decisions are scientifically based, financial ramifications have a way of exerting subtle influence over their interpretation of scientific evidence. We know, for example, that cardiologists who perform cardiac catheterization and angioplasty are more likely to recommend these procedures than are other cardiologists and primary care doctors—though all claim to be guided by the best evidence available. In my experience, doctors rarely recommend procedures simply to make more money, but like most people, they like to use their special skills to help others;

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