Just Doing Our Jobs

Kim BellardHealth care fraud is bad.  Everyone agrees about that (except those who profit by it).  We'd similarly agree it is all too pervasive.  Just in the past few days racketeering charges have been brought against former executives of Insys Theraputics, numerous charges brought against leaders of Forest Park Medical Center (Dallas), 18 people in Pittsburgh were charged in a prescription fraud scheme, a New Jersey chiropractor was arrested for health fraud, and the feds settled a $4.5 million fraud case against a Florida orthopedic clinic.

The list goes on and on, week after week, in every state, for every type of medical specialty, and against most health insurers.  Some estimate that fraud could account for up to 10% of health care spending.  But that's chump change: estimates are that other kinds of wasteful spending, such as unnecessary care and excessive administrative costs, are easily double that.

An op-ed in The Boston Globe may have it right:  we need an overdiagnosis awareness month.

The op-ed was a tongue-in-cheek suggestion to highlight the various cancer awareness months, the most famous of which is October's Breast Cancer Awareness.  These campaigns promote the need for the associated screenings, but don't typically also mention how controversial many of them are.  As the op-ed noted, many screenings result in false positives that end up with expensive additional testing and significant patient anxiety, or in detection of early stage cancers that might never actually present any actual threat.

Overdiagnosis goes much further than screenings.  As Atul Gawande wrote last year, we're getting an "avalanche of unnecessary care," getting too many services of not just low value but of at best no value to patients -- and, at worse, actually harmful to them.  Not just pointless tests or unneeded prescriptions, but also too many questionable procedures, such as total knee replacements, heart stents, or spinal fusions.

Now, in some of these cases -- such as when physicians have direct investment interests in the drugs or devices being used, or in the facilities in which they are done -- the parties involved may be knowingly letting dollar signs outweigh patient interests, just as there are people committing fraud.  But those are by far the minority of people working in health care.

The real problem is that most people involved in the "epidemic" of overdiagnosis and over-treatment our health care system, well, they think they're just doing their jobs.

They don't think they're trying to rip anyone off, they certainly don't think that they're harming anyone, and they most definitely don't think their role is superfluous.  From the lowliest claim adjustor to the most overworked front desk attendant to the highest paid surgeon, and everyone in between: they all think they are performing a necessary service.

This is all only possible because it is still too hazy about what is the right treatment for who, when, not to mention what a "fair" price might be for anything.  So, when in doubt, do more.

As a result, health care employment is booming.  Some project it will be largest job sector within three years.  Indeed, as the chart below shows, virtually all of the U.S. job growth this century has been in health care jobs.  That, quite simply, is astounding.

Yet, despite all this growth, there continue to be urgent cries of shortages of key health care professionals.  We just cannot seem to get enough qualified health care workers.  If you're looking for a job, that's good news, but if you're paying the bill for all those jobs, it should be scary.

Unlike manufacturing, we're not seeing productivity increases in health care, despite massive "investments" in health care IT.  Some argue that health care productivity is actually decreasing, a notion that fits the stereotypes of doctors struggling to input into their newfangled EHRs.

In health care, we just add more jobs.

When hospitals expand, drug companies grow, or health care start-ups jump in the fray, local politicians get all excited about all those added jobs.  Cities like Cleveland and Pittsburgh have been touted as reinventing themselves from dying Rust Belt cities to regional health care hubs.  But those jobs mean more spending, all of which has to get paid for by someone.

Even new research which argues that, contrary to popular belief, market forces do work in health care had to admit:

In other words, we found that patients were attracted to hospitals that used more inputs over hospitals that were just as good but used fewer inputs. This is not a good thing because society is paying for those inputs.

Overtreatment works, at least if you're the one doing the treating.

Health care has won the war.  We all think we need medical attention and treatment.  We've given up any hope of reducing health care spending; we're happy if it just doesn't grow too fast.  We complain about our health insurance premiums, but we don't have any idea if our local hospital is charging more than its nearest competitor (nor do we seem to care if, indeed, there is a nearby competitor).  If our medical treatments don't make us better, or even make us worse, we humbly just submit to more of them; it never seriously occurs to us to ask for our money back, at the very least.

And everyone in health care keeps doing their job.

Look, this fantasy isn't going to continue.  Health care isn't going to become 100% of GDP.  It's not going to get to 50%, or 40%.  At some point the revolt will happen, the revolution will occur, and health care spending will finally slow, stop, and eventually plunge.

Then all those health care jobs are not safe.  People will lose their jobs.  A lot of people.  People who, until then, thought they were doing good.

It's nice to pretend that it will mostly happen to paper-pushers (or, nowadays, keystroke enterers), but in truth some of losses will be for people now providing care.  It's also nice to assume that, if so, it will only be people providing unnecessary care, but there probably won't be such a bright line.  Job losses will cut across the board.

So when the next health care innovator comes along, we should try to get past the hype and ask: OK, specifically, what jobs will this eliminate -- which ones, how many, when?  If they don't have answers, or only offer vague promises, well, smile politely and get out your wallet.

In health care, perhaps one way to do your job might just be to find a way to eliminate it.