Howie and Harlan discuss the financial, institutional, and psychological forces encouraging the use of unproven and disproven treatments and tests that drive up healthcare costs.
Harlan Krumholz: Welcome to Health & Veritas. I'm Harlan Krumholz.
Howard Forman: And I'm Howie Foreman. We are physicians and professors at Yale University, and we're trying to get closer to the truth about health and healthcare.
Harlan Krumholz: Hey, Howie, it's great to get together again. What's something that's happening in health and healthcare that got your attention this week?
Howard Forman: I was interested and surprised to learn in a Kaiser survey that came out yesterday that 83% of all those surveyed are supporters of the currently proposed legislation to allow Medicare to negotiate drug prices with drug companies. And some of the other findings in the survey were that there's strong support, obviously from both Democrats and Republicans in order to get such a high number. And that even when you tell all of the participants in the survey information about both the risks and the benefits that would accrue from such a bill, that there's no change. Literally it goes from 83% to 83% with a mild shift in the number of people who go from “strongly in favor” to “just in favor.” And I'm chagrined to note that when I talk to others who are a lot smarter than I am about health politics, they still think that this is really unlikely to pass.
Harlan Krumholz: Why were you surprised? Don't you think most people see this bill as a way to control costs and are thinking that their drugs are going to be cheaper? And then why are you surprised about what's going on, on the Hill? Because isn't that just about the imbalance between the power of the general public and the immense amount of lobbying that's going on to try to maintain the status quo?
Howard Forman: Yeah. I'll tell you, I'm still surprised because there's so few things that get such huge bipartisan support. And fewer still that when you have that level of bipartisan support, that we're still skeptical that even with Democratic control, that they can hold together all 50 senators and a bare majority of members of the House in order to pass this. So I'm constantly skeptical of government. But in this situation, I would have thought we'd have a greater chance of seeing meaningful legislation pass. And a lot of smart people think that it's just unlikely to happen.
Harlan Krumholz: And I take it you're part of that vast majority of that favors the bill?
Howard Forman: I don't know if I favor exactly the way it's written, but the way the survey is asked, I'm in favor of it. Yes.
Harlan Krumholz: That's great.
Howard Forman: Tell me what's on your mind. What are you thinking about?
Harlan Krumholz: Yeah, well, this week, the U.S. Preventive Task Force, a government group of experts, came together and put out a draft set of recommendations around the use of aspirin and people who are prone to heart disease. And they sort of reverse course from what they said in 2016. They're now backing off of these recommendations that tended to lean toward the use of aspirin in high-risk individuals. Again, people prone to heart disease, not people who have heart disease. And especially as you looked at older groups, they're actually peeling off any enthusiasm at all. Suggesting that if you're over 60 and this is being used to prevent heart disease, the evidence isn't in any way in favor of that. And I'm really actually very much in favor of these recommendations. Again, they're draft at this point; they're out for public comment.
Harlan Krumholz: It will be about a month or so where people can weigh in, but I fully expect them to very much resemble what will be the final recommendations. And it's because there have been a series of studies and re-analysis that have occurred over the last couple of years that have pointed us away from thinking that aspirin for this group is a good thing. For younger people it used to be that for people 40 to 59, there was more of a push-in, and now really it's a toss-up, that the evidence just isn't there. And for older individuals, the risk of bleeding seems to outweigh the benefit of preventing heart disease.
Harlan Krumholz: And so we talk about this as the net benefit. Is there a net benefit? When you take into account all the good things and you subtract out the bad things, where do you stand? And so on average for particularly people over 60, there just wasn't much to recommend it. The important thing, though, is for people to talk to their doctors, if they're contemplating coming off aspirin. And also to realize that this is a very specific group of people—it's a group prone to heart disease but not with heart disease. If you're not even prone, they had already said that aspirin just for prevention isn't a sensible thing.
Howard Forman: It is a reminder, time and time again, about how we must all be humble about what we know and how we have to continue to ask the hard questions to get to the best answers and modify our practice when we learn something differently.
Harlan Krumholz: Yeah, I think there are two things to this. One is, it shouldn't frustrate people with science and medical information. The fact that it evolves over time is a good thing. We always have to make the best decisions we can at the moment that we're making those decisions. And so that depends on the quality of the evidence that exists in that moment. And that's just the way it is, there are always going to be some decisions under uncertainty. Sometimes that uncertainty is extreme. Sometimes it's less, but there's always some uncertainty. And then the fact that “science is progressive and self-correcting”—I take that quote from Francis Collins, who is currently director and will be former director of the National Institutes of Health. He wrote that in one of his books. I like quoting it a lot because I really believe it.
Harlan Krumholz: It's progressive and self-correcting, and so we will always be learning new things. And this agility with regard to recommendations is entirely a good thing. And so then when people make decisions today, they can make it based on more evidence than they could five years ago, and these recommendations should be evolving in real time as we learn more.
Howard Forman: I just finished teaching this segment in my undergraduate class. And it reminds me that one of the more common questions that students ask when I get to this point is, we spend such a huge amount of money in this country. And they'll say to me, "What would you do if you were king? What were the things that you could do that would save some money?" And my answer always is, "Well, I would just stop paying for things that don't work." And so it gets to this question of how do we end up paying for so many things that are either unproven or for which we already have evidence that they actually don't work?
Harlan Krumholz: Before we go into this sort of stuff around what are we doing that we shouldn't be doing, well, we should unpack a little bit just how much more we spend than everybody else. The interesting thing is that we are so far ahead of everyone else in the world in terms of the amount of money that we devote to healthcare, and our results aren't any better. Arguably they're worse than a lot of countries. And if you look at around 1970, we're actually clustered very much with the rest of the world. We're not distinguishing ourselves with regard to how much more we're paying for healthcare. And then somehow the medical-industrial complex really went into high gear. What's your view on them? What was it that was fundamentally the cause of us between 1970 and today really separating from the rest of the world in a profound way and the amount of money we were spending on healthcare?
Howard Forman: One of the things was that Medicare passed in 1965, and by 1966, it was already implemented. And that gave a vast new group, that was going to grow really quickly, new access to care. Then unfortunately, before that, they were having limited access to Medicaid, also passed at the exact same time. So you had new sources of insurance to large parts of the population that were previously denied. But on top of that, it's also a time of incredible innovation. If you think about it, prior to the 1960s we didn't have transplants; prior to the 1970s we didn't have computer tomography, MRIs, echocardiography...
Harlan Krumholz: But the rest of the world had all those innovations too.
Howard Forman: Yeah, but we had deeper pockets to pay for them, and we had a fairly unregulated system for providing them. And I think that America is known for entrepreneurship and capitalism and innovation, and we probably innovated a lot faster in good ways, but we also were willing to spend a lot faster to get that innovation.
Harlan Krumholz: Well, we have this positive feedback loop where... in fact the healthcare profession can dictate, the demand’s not necessarily dictating the utilization, but many studies have shown the supply, so the more CT scanners, the more people doing procedures, the more devices and so forth, the more we did. And so the more you did, the more you grew, the whole system had no check on it.
Howard Forman: A hundred percent. Look, and we can dedicate a whole other podcast to supplier-induced demand and supply-induced demand. If you build it, they will come. And we have proven that in my time at Yale, and even previous to that, there were many times where you had long lists of people waiting for an imaging study, and we knew that if we just added an extra piece of equipment, it would take up all that demand. And as soon as you put that new piece of equipment in place, you had the same demand before. You had more demand, and we just kept creating it. So we know this in real life.
Harlan Krumholz: It led us to acts of commission, always leaning in and doing things and buying new things. Whether it was... robotic surgery is a good example for me. These multi-million dollar machines that were... You've got all these billboards posting and bragging about the existence of these machines. As far as I know, there isn't any convincing study that they actually improved outcomes. What I have seen is that surgeons enjoy them, it seems. But they don't seem to have improved outcomes where they were really worth the cost.
There's a whole range of procedures. I'm a cardiologist, of course. And when we've done studies of people undergoing heart interventions, this is serious business. People have metal placed in their coronary arteries using these stents. And in a study that I considered producing a conservative estimate because it was based on criteria that came from the American College of Cardiology, we found that maybe one in six of certain classes of PCIs—those that were elected, not counting the ones for heart attacks but ones that were just electively done—were in that category of “inappropriate.” And that's just the tip of the iceberg. I mean, orthopedic procedures. There's a whole range of things that are going on in medicine where the evidence just isn't strong.
Howard Forman: Look, we give an awful lot of latitude to physicians to how they practice. We approve drugs, but we don't require physicians to prescribe those drugs for the original indication that were approved for. So what do we do about that? What are the levers that we have within our immediate control or might contemplate in the future that can help us have a more evidence-based delivery system?
Harlan Krumholz: When I teach this, I talk to the students about thinking about these in categories. And I just try to make it simple, because this is how I talked to the patients about it. I'll say, "Look, there's some things in medicine that are a best buy. Their benefits so far outweigh any risks or downsides that they just have a dominant benefit and should be something that everyone..." So when I talk about a best buy, I'm not even talking about the price, I just mean, whatever it takes to go through to get this. And then there's some that are worst buys, like we really have very thin or if any evidence, and usually it can be no evidence that this is really beneficial for you.
And if somebody just says, "But I just want to try it," I think it's up to us to say, “That's out of bounds.” There's certain things, I guess... It may be possible someone wants to pay out of pocket completely, but it shouldn't be something that is being paid for routinely. And if it's really in that out of bounds, and then there's a great middle. Where it really does depend on the patient's preference or there's some uncertainty, the evidence may be some for, some against. And we're trying to sort through and trying to figure out where something sits. But there's a lot of things in that worst-buy bin that are being used routinely in medical practice and in both of our fields and in all fields. Where extra imaging or extra tests or extra procedures where at the margin, there's just so little evidence that this is going to benefit someone, but somehow they get on track to have it.
Howard Forman: And there are really market forces that encourage this. I think back to a family member who had a very low-grade lymphoma. I talked to some of the lymphoma people at Yale and asked her advice. And they said, "Look, once it’s surgically resected, you don't even need imaging following up." And then that person in my family went every year for a PET scan at an enormous expense for I think, five full years after that. And I think it's an example of where the oncologist had an ownership relationship with the piece of equipment. There's probably a radiologist interpreting the study, making money off of that. The patient feels like they're getting something because somebody ordered an exam. They don't feel like they're being harmed by it. There's no cost to them in many cases. And nobody seems to be worse off, except it adds considerable expense into our healthcare system.
Harlan Krumholz: Yeah. This reminds me about the case of antibiotics for kids with ear infections and the large number of patients of kids who ended up getting antibiotics inappropriately. I think there's a psychology to this also. We all know about the financial incentives, but it's just easier to say yes to a patient than no. And when a patient comes in and wants something, and this isn't a blame on the patient, but it's something about the psychology that we'd created about more being better. And it just… as you know, your day goes much faster if you just order it than spend a half hour explaining why they don't need it. And so it works on both sides. I think on the doctor's side, we're constantly thinking more information will be better. That's not always true, but that's our mindset. And sometimes patients, once they know things that could be done are leaning in too and then the money's flowing. So yeah, I think this may be large-scale educational precedent. Do you think there's things that we should be doing in medical school that would prime at least the health profession to be better prepared to think about these issues?
Howard Forman: I think we're doing better now than, for instance, when I was in medical school 35 years ago. But it's certainly not enough. And I do think one of the problems with medicine is that we all become very specialized. We all become enamored of what we do. If you're a spine surgeon and someone tells you that spine surgery doesn't work in a particular area where you've done so many surgeries, it's a lot easier to begin to believe that actually it does work well in my hands because I know how to pick the right patients, and that study doesn't reflect my experience. So I don't think people are acting maliciously, but I do think people act badly for non-malicious reasons, but they do act badly, ultimately, when you look at the data.
Harlan Krumholz: Well, and then you have the health systems that are very much dependent on these volumes. They've made large-scale capital investments and scanners or operating rooms, or whatever they have. Their interest is in keeping hospital beds full. And these flowing... Rob Kale used to repetitively tell the story, when he was in leadership at Duke, that a large part of the leadership meetings were spent on how they were going to make sure that the MR scanners’ schedule remain full. And he was just saying, “Here we are strategically talking about the future of a healthcare system, responsible for a large segment of the population. And here we are talking about whether or not we're doing enough imaging and how we're going to maintain that level.” I can remember when I was... One day I walked into the cardiology office and someone wrote a note on the wall and said, "We have open slots in the echocardiography—the ultrasound waves that we use for the heart—schedule that day. If there's any possibility that any of your patients need this, let us know." Sort of fishing for business that way. And I get it—it's just the way that the whole system is configured. There's no way the health system, at least as far as I can see so far, is going to make a big investment in reducing healthcare utilization. And so we don't want to have these battles where it seems like patient’s interest, healthcare system interest, physician's interest, and society's interests collide. But it seems almost inevitable right now. I don't know. Do you have thoughts about what we should be doing?
Howard Forman: Well, one thing is that I think there needs to be more transparency about both the value as well as the cost of studies that patients are referred for. I've been shocked to see that most medical imaging studies can vary in price by anywhere between 5- and 10-fold in a given region. Which just makes you wonder how will we set prices in this market and how patients can be so ignorant—not their own fault—but ignorant to what they're paying for things when they go in there.
Harlan Krumholz: You know, of course, about the legislation that's pushing out the information about the pricing. Do you think people should be shopping for... If I'm scheduled to get an MRI scan, should I be looking around? Are the reasons I should do that?
Howard Forman: Yeah. So the legislation forces institutions by federal law, by federal regulation, to report both their list price as well as negotiated prices with insurance companies. And that's where that fold variation comes in. Ironically, we're almost a year into enforcement of this, and only about a third of institutions have at least partially complied with the legislation. Which is just shocking to me that even with the force of federal law, you have the majority of healthcare institutions in this country not in compliance with that. But I do think we need to get to a point...
Harlan Krumholz: So I just said, I didn't know that was an option. Can you ignore federal regs like that?
Howard Forman: I am shocked by it. There are some pending lawsuits, and maybe those hospitals are hoping that they will go in their favor, but there are lawsuits out there. Someone showed me a website just about two days ago that shows you how you can look up the prices for any given zip code, but that presupposes that those hospitals have submitted the data for that region.
Harlan Krumholz: Yeah. Just to say, it's not that unusual. There'd be the regs on the books around the necessity of institutions to share data back with patients in the form that they want across a wide spectrum of types of information that they have in their electronic records and in their radiology systems, and most don't. And you and I have participated in a study after it was clear that people have a right to their own data. And in a secret shopper study we did with a medical student, I think you and I were both shocked to find out just how difficult it was for people to get their own records. Even though the law was on their side. So many of these institutions were ignoring those regs. So maybe… I'm hopeful in the future that'll change, but that was frustrating.
So, we're getting to the end. I don't know that we've given anyone any solutions, but do you have any final thoughts on this topic before we get to the end?
Howard Forman: Just that the... You started off talking about the aspirin story, and that does give me hope. Because I do think that the more information we get out there, the more that specialty societies and organizations can come to agreement on best practices. The more hope we can have that we can get physicians and other practitioners to be aligned about what are the things that are in the best interest of the patient.
Harlan Krumholz: Yeah. And there was this program that still is going on called Choosing Wisely where the American Board of Internal Medicine Foundation convened groups of specialists and said, "What are the top five things that you think are being done in your area that shouldn't be done? And can we promulgate that and help educate about it?" I can't say whether or not it actually changed practice. I think what was most amazing to me was that most of these groups had no problem coming up with the top five things that they thought were overused. And that in itself was emblematic of the kind of problem we have. If you can convene a group in and say, “What are the top five in there?” and they've got an abundance of suggestions about overuse, then that just points to the importance of the problem.
Look, as we get to the end, we always like to end on a note of something that is either keeping you up at night or has brought a smile to your face. What's yours this week?
Howard Forman: I think a lot about… There’s a song called Fanfare for the Common Man, which is Aaron Copland wrote around World War II. And it was an inspiring piece about the common man during World War II fighting directly and even providing service back at home. And it just reminds me that in the last 20-plus months, there are millions and millions and millions of people who have just served quietly in the background during this pandemic and made the gears of our country work and allowed us to continue the work of healthcare and teaching that we do here. And I'm just reminded so much about this when I see that the disruptions that occurred in airlines this week, particularly Southwest Airlines, and the disruptions that are going on in shipping and in our supply chains right now, that there are just so many people that work so hard every day to just make things work. And we don't often reflect on them. And I personally am inspired by every one of them and just thankful for them. And I wish we could go back to a time that a symphony orchestra would play a song in dedication to them.
Harlan Krumholz: That's a nice thought.
I'll tell you what this week for me… So I had the pleasure this week to go for a walk with our colleague Marcella Nunez-Smith. And as you know, Marcella is one of the most extraordinary people that we know, a colleague for a long time, a professor at Yale in general medicine, but importantly is the Biden administration's lead on the task force on health equity and has been working for a long time, even before the administration took over, on trying to ensure both that we were paying attention to health equity issues in the country, finding strategies that will promote better equity, and then in the midst of the pandemic, doing such terrific work to ensure that all communities in our nation have access to the vaccine and to good information about the vaccines’ terrific benefits and balanced information about what needs to be monitored. And gosh, just talking to her, I was just so inspired by both her work and by the kind of time and effort and her dedication in public service. And it both reminded me of how we're surrounded by so many people in this institution who are playing such a key role in promoting the public health and in contributing to government efforts and beyond to improve the health of people in this country and internationally. But particularly it's just such a privilege to hear from Marcella, to have a few minutes with her, and to know that the nation's in a better place because of the kind of efforts that she's making on our behalf. So anyway, that brought a real smile to my face this week.
Howard Forman: I'll also point out as with you, she is one of the most effective mentors to our undergraduates, our graduate students, our medical students, and so on. So we're very fortunate to have her here.
Harlan Krumholz: You've been listening to Health & Veritas with Harlan Krumholz and Howie Foreman.
Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.
Harlan Krumholz: @hmkyale, H-M-K-Y-A-L-E.
Howard Forman: And I'm @thehowie. That's @thehowie, T-H-E-H-O-W-I-E.
Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Talk to you soon, Howie.
Howard Forman: It's always a pleasure Harlan. Thank you very much. Talk to you soon.