Open wide and say, ‘Ah’
In 1945, the New England Journal of Medicine, citing a 1934 study, suggested the dangers of presenting one’s tonsils for a medical examination. Despite the great advances in medicine, I wonder whether our thinking about medical procedures has significantly advanced in the 80 years since publication of this study.
The American Child Health Study surveyed 1,000 school age children in New York and discovered that 61% had their tonsils removed. The remaining 390 were examined by a group of physicians who selected 45% for tonsillectomy and rejected the rest. The rejected children were re-examined by another group of physicians who recommended tonsillectomy for 46% of these children. When the rejected children from the 2nd set of physicians were examined a 3rd time by another group of physicians a similar percentage of children was selected for tonsillectomy. Consequently, following the three examinations only 65 children out of the original 1000 remained without a recommendation for tonsillectomy. These children were not further examined as the supply of physicians was depleted.
The investigators found no correlation between the estimate of one physician and that of another; the authors concluded that the chance of a child being recommended for tonsillectomy depended on the physician rather than the health status of the individual.
This study illustrates two problematic themes in health care:
1. Unnecessary variation. Care was driven by differences in physicians rather than differences in health status
2. Supply driven demand. The recommendations for tonsillectomy depended on the supply of physicians.
A 1994 study of tonsillectomy rates in western countries showed unnecessary variation 60 years after the New York study. Tonsillectomy rates (ages 0-14 years) between countries varied 6 fold from a low of 19 per 10,000 in Canada to a high of 118 in the Netherlands. The U.S. rate was twice the Canadian rate.
All of this brings me to a conversation occurring among parents as we watched our daughters play in a soccer tournament. A parent described the care she recently received outside of Park Nicollet. She saw an ENT physician for a long standing nasal stuffiness. As she spoke, my primary care training silently translated her symptoms into a diagnosis of “vasomotor rhinitis”- basically chronic non-allergic stuffiness that is annoying but part of the spectrum of normal. During my medical practice, I would have approached this complaint by talking with her, looking at the nasal lining with an otoscope and offering symptomatic treatment with a spray. After seeing the ENT physician twice, she received a bill totaling over $2,000 including a C-T scan of the sinuses and 2 nasal endoscopies requiring mere seconds to perform. She has insurance with a high deductable and was shocked when she was given no warning about how much the procedures would cost and the chances of benefiting from the X-ray exposure and the nasal endoscopies.
My soccer field interaction illustrated many lessons during the long tournament day:
1. The U.S. healthcare payment system rewards volume (“doing stuff”), not value.
2. Rewarding volume breeds unnecessary variation and supply driven demand (sinus C-T scan and 2 nasal endoscopies in the example above)
3. Unnecessary variation and supply driven demand increases costs, does not enhance quality and at times may expose patients to risks
4. High deductibles make patients more aware of the costs of care.
What do you think? Please feel free to leave a comment. As always, we encourage a free exchange of ideas, but we reserve the right to remove comments that make personal criticisms or attacks on individuals or specific businesses.