In Conversation With… Rosemary Gibson, MSc
Approach to Improving Safety
Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA Internal Medicine. She led national initiatives to improve health care quality and safety at the Robert Wood Johnson Foundation for 16 years. She is the principal author of The Treatment Trap, which explores reasons behind overuse of unnecessary medical treatment. We spoke with her about overuse of medical care and its effect on patient safety.
Dr. Robert Wachter, Editor, AHRQ WebM&M: What is the magnitude of overuse in medicine?
Rosemary Gibson: We don't measure the extent of overuse so we don't know its magnitude. I believe it is pervasive.
RW: As you look at the pathophysiology of it, are you convinced that financial drivers—which I guess I interpret as being the more you do the more you get paid—are the dominant reason for overuse? What evidence supports that?
RG: Yes, financial incentives are the dominant cause of overuse. But other factors contribute to overuse. Uncertainty in medicine drives overuse. A natural proclivity may be to do something in a context of uncertainty. Fear of malpractice suits drives overuse. Beliefs are a factor. Physicians and patients have their beliefs about medicine and its possibilities and limitations.
The enthusiasm factor is widespread, as Dr. Mark Chassin, CEO of The Joint Commission, reminds us. Even when evidence proves that an intervention is not effective, enthusiasm for it overwhelms objectivity. A case in Maryland of unnecessary stents involving nearly 600 people illustrates this phenomenon. A physician who assumed responsibility for the care of some of these patients, after the doctor involved stopped practicing, said that a small subset still believed that the physician who performed the unnecessary procedures saved their lives. The enthusiasm factor is alive and well because of what I call "the marinated mind." Our minds have been marinated by the media and marketing to believe that more is better. We need to dilute the marinade.
Finally, publicly-traded companies that sell drugs, devices, and equipment are a powerful driver of overuse. Their primary fiduciary duty is to shareholders and they are obligated to maximize shareholder value. This goal can be achieved only by selling more products and increasing the price. Selling more requires doctors to use more of their products in surgeries, tests, and prescribing practices.
RW: How should we tackle this problem?
RG: Different solutions are needed to address the varied causes of overuse and its harm. There are two kinds of harm from overuse. The first occurs when a patient has an unnecessary procedure, such as back surgery or cardiac procedure. The patient is exposed to risks of the procedure.
Second, as productivity demands increase, stress on the delivery system to do more in the same amount of time heightens the risk of mistakes and the potential for harm. I use the I Love Lucy chocolate factory video to illustrate this point. In the video, Lucy and Ethel are wrapping chocolates on an assembly line. The conveyor belt speeds up and they do workarounds to handle the faster pace. They demonstrate to their supervisor that they can manage the faster pace, when in fact they cannot. The supervisor ramps up the pace even more, and everything goes downhill.
That's exactly what's happening in health care. When a system with defects is forced to operate at a faster pace, performance degrades and mistakes increase, creating more opportunity for preventable harm.
RW: So the reasons for overuse include financial incentives, cultural beliefs, marketing, and production pressures. Take us through what you think some of the solutions are.
RG: Identify outliers where overuse is apparent and publicly report hospital-specific data. Public reporting of hospitals' early elective deliveries without medical necessity is an example of the utility of transparency. It raised awareness and motivated improvement.
Public reporting of double chest CT scan data from Hospital Compare is another good example of how transparency generated improvement. The New York Times and the Washington Post published interactive maps using Medicare data that identified hospitals around the country that had high rates of unnecessary double chest CT scans. Transparency raised public awareness of overuse and motivated reductions in inappropriate use. As we begin to develop a critical mass of early adopters of appropriate use, the next step is to cut reimbursement for double scans, thereby aligning incentives to provide appropriate care.
RW: Should we dial down reimbursement for everything or pare back specific areas of overuse?
RG: We need to do both. We need to target specific areas of overuse and develop knowledge and skills to reduce it. We need to be honest about the harm from the overuse. Not all overuse results in harm but it can. When a child gets an adult dose of radiation, this is not just overuse. The child is exposed to unnecessary radiation. An early elective delivery without medical necessity is not just overuse. A newborn can be harmed by it. Overuse is a patient safety concern, not just a financial burden.
Our country also needs to set limits on the rate of growth in health care spending. Without limits, we will be successful only in reducing unnecessary use of particular tests or procedures. Meanwhile, overuse of other interventions will pop up. The "whack-a-mole" strategy does not work. The most vociferous opponents of limits on spending growth will be those who are dependent on revenue growth for their survival. Let's be clear. Health care spending levels are not sustainable. A graph from a 2007 CBO report shows that if historical spending trends persist, by 2082 we'll be spending 99% of our GDP on health care. The recent slowdown in spending growth will moderate these projections somewhat to say, 80% of GDP. Still, we cannot keep doing what we are doing.
RW: Is your recommendation that we focus on the clinical harm rather than the finances in terms of trying to get the message out?
RG: We need to do both: highlight the harm to patients and set limits on spending growth. Health care journalists have contributed to the public debate on overuse with front-page articles in the New York Times, Washington Post, and Wall Street Journal on overuse of back surgeries, stents, among other interventions. Public comments on these articles are enlightening. A subset of the public is deeply attuned to the harms of overuse and are dismayed by it. The drumbeat should continue. We need reporting by hospital of measures of overuse, which we don't have too many of, that will shine a light on outliers and galvanize improvement.
RW: Your sense is that transparency has a huge bang for the buck. That good things flow from putting out appropriately adjusted data and demonstrating patterns of variation, particularly when the media gets ahold of it. An alternative approach would be to say we must be even more proactive. Regulators need to get involved, boards need to be looking at this, and payers need to be looking at these variations and stop paying for these things. Is your feeling that transparency comes first, or should all of this be happening at the same time?
RG: Transparency comes first to build awareness and understanding of the human and financial cost of overuse. Next, promote learning to reduce overuse. Finally, cut reimbursement as South Carolina Medicaid and Blue Cross have done for inappropriate early deliveries.
RW: When you talk to practicing physicians about overuse they have almost an inkblot response. One is malpractice and the second is patient-driven demand. What do you think and what can be done about those two areas?
RG: Fear of medical malpractice drives overuse. The dreaded thought of missing a cancer diagnosis leads to overtesting. At the same time, the fear of being sued is probably not the motivation for cardiac procedures performed on patients when there are no blockages, or for most complex back surgeries that result in increased morbidity and mortality. Overuse is causing medical malpractice suits.
RW: Obviously physician groups often advocate for some sort of legislative changes to the malpractice system that might help here. Are you sympathetic to those calls at all?
RG: Early evidence suggests that health care organizations that are honest with patients in the aftermath of preventable harm can have dramatic reductions in medical malpractice claims and premiums. This is where I would start to bring down the cost of medical malpractice. Second, examination of the root causes of preventable harm and repeated patterns of harm offers valuable information about systemic risks and provides insight to make dramatic improvements in safety, as anesthesiologists have discovered, resulting in dramatically lower malpractice premiums. Third, a small subset of physicians account for a disproportionate number of malpractice claims. It is not clear that medical malpractice insurers have handled this disproportionate share issue satisfactorily. Finally, some lawyers on both sides are too keen on generating income rather than resolving cases. For this reason, the best strategy is prevention.
RW: How about patient-driven demand?
RG: Our minds have been marinated to believe more is better, and we've bought into it. So how do we turn our brains back on? It's not easy to do, but the good news is that some people clearly understand now that they might be getting medical care that's not warranted. When I give talks I ask two questions, have you or someone you know ever had medical care that you or they thought was unnecessary? The range of those answers goes from 30% up to 80%. At a National Patient Safety Foundation meeting, 80% of people raised their hand indicating that they knew somebody. The second question is: have you or someone you know ever declined a treatment option recommended by a physician, because you or they thought it was over the top? Then did you seek a less intensive or invasive alternative that met your needs? And a slightly smaller percentage raised their hands.
That tells me many people are thinking about this and being more involved in their medical decision-making. Then again, some people have no clue. And that's deeply worrisome. So at least we're on this curve of starting because we do so much in health care. People are finally getting the picture: This doesn't make any sense and I'm worse off because of it.
RW: In some ways, these are extraordinarily complex issues, and the simple cases are when we know this thing doesn't work. But the harder cases, which may be even more prevalent, are when it might work but the probability that it's going to work is very, very low and it's usually expensive. How do we deal with that circumstance?
RG: It's very hard for people to make these complex decisions weighing the potential for benefit vs. the potential for harm. I think we can begin by helping people develop the skills to make good decisions about relatively simple, less consequential tests or procedures so they can gradually develop competence in medical decision-making.
An example might be dental x-rays. Are they really necessary every 6 months or every year? If not, we can empower people to politely, but firmly, decline repeated x-rays or other unnecessary tests or procedures. I remember a state legislator who approached me after a talk I gave on overuse of diagnostic imaging. He goes to his doctor every 3 months and gets a chest x-ray. I asked him if he had any underlying condition, and he said no. Then I asked him what he thought about these repeated tests after hearing the talk I had given, and he said that he needed to talk to his doctor about whether they were really needed. This conversation taught me that we can help people examine their own patterns of health care use and begin to ask questions about whether it is appropriate.
The public also needs examples and good medical decision-making. What do you ask? How do you ask? And coming from real people who've made those same types of decisions and how they went through it.
RW: Do you feel that having patients have some financial skin in the game is a force for good in terms of patients being more sensitive to trying to find that information, asking that question, getting educated? Or are the negatives so strong that it's not a favorable trend?
RG: Yes, people should have some financial stake, so they have an incentive to choose wisely. It addresses the so-called moral hazard that occurs when people use more health care services because insurance insulates them from the full cost. But another moral hazard is even more problematic: Health care organizations that build new cancer centers or cardiac facilities to grow market share and rival a competitor's facilities across town are using the public's money to create duplicative capacity. Excess capacity in a community is overtreatment waiting to happen. These market dynamics won't stop until the money stops.
RW: Let me ask you about the future. What do you think this all looks like 5 or 10 years from now?
RG: The health care cost burden will continue to weigh heavily on many Americans, reducing both necessary and unnecessary use. More health delivery systems will be for-profit. Mergers and consolidations will continue, resulting in fewer, larger health care systems. This trend will parallel the consolidation in the banking industry. Countervailing forces to balance excesses will be few and far between.
RW: You're working on the JAMA Internal Medicine series, "Less Is More," and there is Choosing Wisely—so at least elements of the profession have begun talking about these issues in ways that they weren't before. Are these meaningful changes?
RG: Yes, meaningful change to reduce overuse is taking place but only in small pockets where dedicated physicians are endeavoring to ensure patients get the care they need, not the care they don't. Far more powerful forces, however, continue to drive overuse. I'm an optimistic person but the challenges are daunting.
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