To show that I am an equal-opportunity critic of the way “health” care is delivered, I cite Consumer Reports’ list of the 10 most overused/costly services provided by traditional medical care providers. [H. McKinnon “Think Twice Before They Slice” Seattle Times Nov 23, 2007] Of course, criticism must also cite insurance payers who base their payment on the prevailing (“usual and customary”) prices that physicians charge for the procedures they deliver, rather than applying the principle of value-based purchasing. If payers identified and paid for the best benefit vs. cost value, rather than what is delivered and charged for it, there would probably be a lot less care of dubious value, not merely proven safety and efficacy, but “competitive” value to patients, being delivered.

The Consumer Reports’ top ten most overused tests and treatments began with back surgery, which was reported to cost $20,000 in hospital fees plus what surgeons charged, on average. Since in 90% of cases of slipped disk, according to Consume Reports, patient’s pain goes away on its own within six weeks, and patients ended up with the same outcomes after two years whether they had surgery or not, this procedure made the top of the list. Even the American Family Physician recommends conservative treatment of back pain, with 90% of patients usually able to return to work relatively quickly after minimal intervention. [L. Barclay “Recommendations Issued for Treatment of Nonspecific Low Back Pain” Medscape Medical News Nov 28, 2007]

“Heartburn surgery” at $14,600+, came in second, since it did no better for patients than OTC Prilosec at <$1 per day. Prostate surgery and radiation therapy came in third, since they costs $17,000+ and have numerous negative side effects on men’s quality of life, compared to “watchful waiting” for slow-growing prostate cancer. Implanted defibrillators came next, with their $90,000 lifetime costs, since it was asserted that roughly 1/3 of patients with them may not need them. Coronary stents where prescription drugs do just as well were next, and cesarean section adding an average of $7,000+ to costs of delivery, once used in under 20% of births, and most recently in 30.2%, primarily for convenience rather than medical need, cams next.

Full-body CT scans costing $1000 with no proven benefit and added risks due to radiation came next. High-tech angiography CT scans adds $450 to the costs of diagnostic tests, and often require standard angiography as well. While high-tech mammography often fails to improve breast cancer detection significantly, and results in needless biopsies adding further to costs. Virtual colonoscopy is not as good as the “real” alternative, and often a real one is required if there are suspicious findings.

I cannot claim to have checked Consumer Reports findings against the latest research, and I lack any medical credentials, but the list of ten at least illustrates the tendency for the value of a given test or treatment not to have much to do with how often it is used, compared to how frequently lower-cost but equal-benefit alternatives. It seems odd that third-party payers have only recently come up with programs aimed at identifying which treatments for which patients represent the best value, and at least publishing, perhaps paying differentially for best-value vs. questionable-value options.

Certainly patients will want what providers tell them is the best test or treatment, particularly when they pay so little of the costs of the best that they have no reason to prefer to prefer anything cheaper. But when the most expensive is not proven to be the best, by some significant degree over other alternatives, and in many cases offers a distinctly lower benefit/cost ratio, it is at least helpful to have organizations such as the publishers of Consumer Reports that can raise questions.

As consumers become increasingly significant as payers for care, as well as users of it, they need such help in raising the same kinds of questions as consumers should ask about the qualifications of providers of non-traditional tests and treatments, such as those I discussed in my earlier posting on “The Profit Motive and the Placebo Effect”. Physicians are as susceptible to the profit motive as are normal human beings, I would imagine, as well as what Mark Twain characterized as the “Law of the Hammer”, where each specialists’ particular “hammer” makes a lot of things look like they need each’s “nail”, when other options may be more beneficial or valuable to patients.

It is clearly time for the providers of health care to become as concerned about the value of the services they offer, as well as what they get paid for them. It is the lack of proven value that justifies payers’ parsimony, and only proven value that is likely to nudge them toward generosity, as is already occurring with proven ways to reduce the incidence and prevalence of disease in the first place. Just as prescription drugs should have to show that they are better than other alternatives, so should medical care have to prove its value to justify its costs.