Medicine's Rising Costs Put Hippocratic Oath At Risk

Dr. Gregg Bloche says physicians are routinely pushed to be both caregivers and cost-cutters. i i

Dr. Gregg Bloche says physicians are routinely pushed to be both caregivers and cost-cutters. iStockphoto.com hide caption

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Dr. Gregg Bloche says physicians are routinely pushed to be both caregivers and cost-cutters.

Dr. Gregg Bloche says physicians are routinely pushed to be both caregivers and cost-cutters.

iStockphoto.com

In most medical schools, students recite the Hippocratic Oath together to mark the start of their professional careers. The soon-to-be physicians swear to uphold the ethical standards of the medical profession and promise to stand for their patients without compromise.

Though the oath has been rewritten over the centuries, the essence of it has remained the same: "In each house I go, I go only for the good of my patients."

But the principles of the oath, says Dr. Gregg Bloche, are under an "unprecedented threat." In The Hippocratic Myth, Bloche details how doctors are under constant pressure to compromise or ration their care in order to please lawmakers, lawyers and insurance companies.

Bloche says that doctors are increasingly expected to decide which expensive tests and treatments they can and cannot provide for their patients. Their dual role as examiner and cost-cutter can then potentially compromise patients' care, he says, particularly when insurers and hospital administrators urge physicians to only perform "medically necessary" treatment.

The Hippocratic Myth by Dr. M. Gregg Bloche
Palgrave Macmillan
The Hippocratic Myth: Why Doctors Have to Ration Care, Practice Politics, and Compromise their Promise to Heal
By M. Gregg Bloche M.D.
Hardcover, 272 pages
Palgrave Macmillan
List Price: $27

Read An Excerpt

"The average person thinks that 'medically necessary' care means all care that might potentially be beneficial," he says. "But the reality is that it's a wide-open term."

Care may be denied, says Bloche, for a variety of reasons, including whether patients have consented to cheaper treatment options through their health insurance plans. What that means, he says, is that doctors who ration care on behalf of insurance providers may simply be following their patients' wishes — even if patients are not aware that they're receiving subpar treatment.

"In the real world, the choices aren't made clear in the employee benefits office," he says. "In the real world, the cheap health plan and the expensive health plan both promise you 'medically necessary' care and you don't really know what that means. So you sign up for this care and you think, 'Aha! This one's cheaper than the other. And it's promising medically necessary care. You don't really know that one car is a Lexus and one car is a Chevy. These two plans are being presented to you as Lexuses. And so you say, 'I'll buy it.' But in fact, in terms of the care it makes available, it's cheap because it's a Chevy, not a Lexus."

Talking about potential tradeoffs in care is a conversation that doctors and policymakers need to have, says Bloche, because it's inevitable that our health care system will need to find ways to set limits on care.

"We cannot afford anything like what we're spending on health care today, and we're certainly not going to be able to afford what we're projected to spend in the future," he says. "We spend almost a fifth of our national income today on medical care. And within 25 years, unless we change dramatically, we're going to be spending a third of our national income on medical care. And we're doing that by borrowing from our kids."


Interview Highlights

On the rationale of withholding care:

"The rationale there is that the doctor who stints on care three years later when you get really sick is acting in accordance with your preferences as you expressed them in the employee benefits office three years before," says Bloche. "And therefore, the doctor is not violating the Hippocratic Oath. The doctor is merely complying with your preferences when you rolled the dice in the employee benefits office."

On insurers not being required to reveal their criteria to providers for what claims they'll pay:

"This is a walk on the wild side. I've taken on some of these cases for people that I know, and one thing about it, if you know the system's hypocrisies, then you can beat the system. One of the hypocrisies is that the companies take the position that their guidelines for what they will and will not pay for are trade secrets — that they're proprietary. Now imagine a legal system in which the laws were considered trade secrets and their lawyers weren't allowed to know the laws in advance because that would mean they could game the system. That doesn't fit with our legal values, our due-process values — but that is what happens for many, not all, health plans. They take the position that they're not going to reveal in advance the rules for what they'll pay for and won't pay for because that would enable doctors and patients to game the system."

On randomized clinical trials:

"What's amazing is that probably only 10 to 20 percent of the treatments that doctors use today have been tested [in] randomized clinical trials. Even when a treatment is shown to work really well for the sample that's studied in the clinical trial, in the real world patients are all different. [They] vary hugely. So we're never going to be able to have solid science that can tell us for sure whether the treatment is going to work or not. So let's do the research but let's be realistic and pragmatic about the limits of that research."

Excerpt: 'The Hippocratic Myth'

The Hippocratic Myth by Dr. M. Gregg Bloche
Palgrave Macmillan
The Hippocratic Myth: Why Doctors Are Under Pressure to Ration Care, Practice Politics, and Compromise their Promise to Heal
By M. Gregg Bloche M.D.
Hardcover, 272 pages
Palgrave Macmillan
List Price: $27

Stakeholders, Wonks, and The Setting of Limits

It would be wonderful if we could contain medical costs by selectively eliminating care that yields no clinical benefits. That's what Washington's health reformers keep promising. Withholding care that saves lives in order to save money is as unspeakable in Congress as it is at the bedside. And yes, there's some truth to what I was asked to say as an Obama surrogate about opportunities to slash medical spending that buys us nothing. There's the 30 percent of health spending that's wasted on worthless care1—about the price of the $700 billion mortgage bailout, squandered each year. Plus there's the 10 percent or so of medical spending that covers avoidable administrative costs — another $200 billion a year. It surely makes sense to target this spending, by learning more about which tests and treatments work, cutting out those that don't, and getting rid of pointless bureaucracy.

But cutting out the care that's useless is astonishingly difficult. Most people think that doctors know which tests and treatments do and don't work — for most patients, at least. So did I, until it dawned on me a few months into medical school that my pediatrician had put one over on me by telling me he knew his nostrums would help. I'd fled, as an eight-year-old, from his allergy shots — under the examining table, up some stairs, and into a closet out of his reach. And, it turns out, the sorcerer's mix of mold, pollen, and mammal hairs he injected into me weekly, when he could catch me, hasn't been shown to work, notwithstanding the hundreds of dollars my parents spent on the stuff. My medical professors challenged me and my fellow first-years to insist on proof — and showed us that many of the treatments

in common use do nothing. The same year, the Office of Technology Assessment (an agency that advised Congress on scientific questions until it was shut down in 1995) estimated that only about 10 to 20 percent of medical procedures rest on "gold-standard" evidence — randomized clinical trials.

It's doubtful that this percentage has changed much in the thirty years since. The challenges are daunting. Drug companies, makers of medical devices, and clinical specialty societies fiercely resist efforts to compare tests and treatments and to condition payment on proof of effectiveness. There are classic horror stories, including that of the back surgeons who arched their backs when a federal agency empowered to make science-based treatment recommendations concluded that evidence favored fewer spinal operations for lower-back pain. Facing down this threat, they convinced Congress to geld the agency by barring it from issuing clinical guidance.

A more recent example is so-called "CT angiography," which sums up serial, CT slices of the heart to create stunning three-dimensional views of clogged (or clear) coronary arteries. These images allow a glimpse inside the heart without so much as a needle stick. But whether this look enables doctors to save lives is uncertain. Their use soared in 2006, after General Electric brought high-resolution, 64-slice scanners to market. Medicare officials became alarmed about the cost. In December 2007, the agency that runs Medicare said it would pay for the scans only in limited circumstances and only if the doctors who did them participated in studies of their effectiveness. Physicians who'd invested in the machines went to war, demanding that Medicare cover the scans without condition. They lobbied Congress (as did GE), getting 79 Members to sign onto a letter asking the agency to pay for them without limitation. Three months after its December announcement, Medicare reversed course, saying it would cover the test without restrictions and offering only "hope" for future studies of the scans' effectiveness.

Risky and pricey therapies routinely make their way into common use without such studies. Recent examples include hormone replacement for post-menopausal women and use of tiny screens coated with anti-clotting drugs to prop open coronary arteries; both treatments made headlines when federally funded clinical trials found that they killed more people than they saved. Another federally funded study, also conducted after-the-fact, revealed that a whole family of new, patent-protected antipsychotic drugs, adopted by most psychiatrists in the 1990s in response to aggressive marketing, performed no better than cheap, generic medications.

What was most remarkable about these episodes was that rigorous studies were eventually done. The CT angiography story is more typical: new technologies stream into the market with minimal attention to their comparative efficacy. Private insurers won't pay for such studies for reasons that are right out of Economics 101: a finding that a therapy is ineffective benefits all insurers, not just the firm that funded it. Comparative effectiveness research is, in economics lingo, a "public good" — its results are available to all (through publication) and so can't be used by one health plan to get a leg up on its rivals.

Change is looming. The 2010 health reform law created a "Patient- Centered Outcomes Research Institute," funded by levies on Medicare and private insurers, to sponsor such research. But the funding level, less than a tenth of a percent of what Americans spend on health care each year, will do little to increase the fraction of medical decisions that rest on science. And the Institute's governing body — composed mostly of representatives from the hospital, insurance, and drug and device industries, as well as physicians — seems almost designed to enable stakeholders to block studies that threaten their interests. Moreover, multiple provisions in the law (sought by providers and drug and device makers) hobble Medicare's ability to base coverage decisions on research the Institute sponsors.

Excerpted from The Hippocratic Myth: Why Doctors are Under Pressure to Ration Care, Practice Politics and Compromise their Promise to Heal by M. Gregg Bloche M.D. Copyright 2011 by M. Gregg Bloche M.D. Excerpted by permission of Palgrave Macmillan. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

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Why Doctors Are Under Pressure to Ration Care, Practice Politics, and Compromise Their Promise to Heal

by M. Gregg Bloche

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