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on March 5, 2008
Read this book.

If you are in the American healthcare system, this is the single most important book you will ever read. If you are in a healthcare system that is moving towards "privatization" or "free market reform", this may be the most important book you will ever read. If you are a behavioral scientist interested in the role of behavioral factors in medical populations, this is the most important book you will ever read.

A science journalist with a real science background (an M.S. in Biology) and now a Fellow at the New America Foundation, Brownlee has brought together many strands of research to provide us with a picture of the core dilemma in the american health care system - why do we spend so much more than other industrialized countries while not producing better outcomes? At 16% of Gross Domestic Product (and climbing), the American healthcare system is 60-100% more expensive than any other industrialized country and yet we do not live as long as citizens there. Where all these countries cover 100% of their citizens, the American system leaves about 15% of its population (about 47 million people) uncovered at any one time (and even more if you include loss of coverage for extended periods, but not a whole year). Fifty percent of bankruptcies in the U.S. are due to medical bills. Americans avoid switching jobs for fear of losing coverage for pre-existing conditions. The U.S. manages to achieve these colossal failures while still expending 62% of all costs through the government (if civilian government employee's coverage is included as part of the government supported costs).

While there are many contributing problems (profiteering by insurance and drug companies, a system which rewards physicians for doing more rather than just what is proven effective, malpractice anxiety leading to defensive practice, lack of coverage for primary preventive and mental health care which could avoid more expensive emergency care, etc.), Brownlee demonstrates that the core issue is a lack of clinical research to guide physician's decision-making. Where ambiguity exists (and it exists in up to 80% of healthcare), variability in "standard" care is great, and unnecessary care and expense mounts. As a comic strip character once observed: "We have met the enemy, and he is us."

Starting with the studies by John Wennberg and the Dartmouth Center for Evaluative Clinical Sciences, Brownlee reviews the high level of variability (up to seven fold) in the use of various procedures across the U.S. Wennberg's observation is that in U.S. healthcare, "geography is destiny". The kind of treatment you receive depends upon where you live, not what your illness is. And the characteristic most strongly associated with unnecessary care is the number of specialists. If we build it, they will come. The normal operation of a free market is distorted in healthcare by: socialization of costs; the desperation of patients and families; the vast difference between "buyers" (patients) and "sellers" (practitioners, hospitals, drug companies) in understanding what actually works and the tradeoffs in outcomes; and the placebo effect and spontaneous remission. But isn't it part of our duty to protect patients from unproven, and potentially harmful, interventions? If outcomes were improved in the more aggressive geographic areas of the country we might be able to claim that the less costly areas are undertreated, but they are not. In fact, in most comparisons, patients are, if anything, worse off with the more aggressive care. Remember that Hippocratic dictum: "Primum, non nocere" (First, do not harm)? The propensity of U.S. healthcare is to "do something" rather than accepting the patient's status as perhaps better than the potential harm occasioned by aggressive intervention. For those of us raised in the era of "If it might help, do it", this is tough medicine to swallow. But it is necessary medicine.

Brownlee acquaints the reader with many of the more egregious failures of the system: back surgery for chronic low back pain; mastectomy (vs lumpectomy) in breast cancer; bone marrow transplantation in breast cancer; PTCA for event, or even chest pain, reduction in coronary heart disease; fen-phen for weight loss; carotid endarterectomy in asymptomatic patients; surgery for prostate cancer, etc.

One implication of all this is that the highest priority for medical research should be clinical trials that clarify the effectiveness, safety and efficiency of various treatments. The hostility of the NIH to this task is captured by a quote from its director: "We don't do Coke versus Pepsi". Fine. If the NIH is uninterested in improving American healthcare (it's congressionally mandated mission), defund the NIH and put the money into the Agency for Healthcare Policy and Research - the folks who blew the whistle on back pain surgery and were subsequently assaulted by the Orthopods bribing Congress. The priorities for public funding should exactly answer us about "Coke versus Pepsi", because that's where lives are won or lost. Cellular, subcellular and genetic research has such a low rate of clinical payoff that it ought to be the minor theme.

See my blog on evidence based healthcare reform:
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on September 20, 2007
Shannon Brownlee's manifesto, Overtreated, is a an extraordinarily important volume for those of us who question the mercantile thrust of health care in these United States. The sad reality is that to many physicians, hospitals, insurance carriers, and, of course, most pharmaceutical companies the American patient is a valuable cash cow. This impeccably researched book will allow the reader to make informed health care decisions. It is lucidly written and difficult to put down. It should be required reading for all who find themselves on the consumer end or "health care." As a physician, I will keep copies in my office for patients to peruse and borrow. Thank you, Ms. Brownlee for shedding light on a dimly lit landscape.
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on March 10, 2008

"[This book] is an exploration of three simple questions:

(1) What drives unnecessary health care?
(2) Why should we worry about it?
(3) And once we understand how pervasive it is in American medicine, how can we use that knowledge to create a better system?"

The above is found in this stunning, eye-opening book authored by medicine, health care, and biotechnology and award-winning journalist Shannon Brownlee.

Note that even though this book concentrates on the American healthcare system, what it says can be applied to the Canadian and European systems as well.

People familiar with the problems in healthcare will be familiar with some of the contents of this book. What they won't be familiar with is the true-life patient and whistle-blower stories (many of them ending up tragically) that Brownlee discusses to drive home the points she makes.

Almost every page has something interesting on it. I will provide a sample sentence from each chapter of this gripping book (these are just the tip of the iceberg):

(1) "As research would show over the coming decades, stunningly little of what physicians do has ever been examined scientifically, and when many treatments and procedures have been put to the test, they have turned out to cause more harm than good."
(2) "Every patient admitted to a hospital risks being hurt or even killed by the very people who wish to help her."
(3) "After blowing the whistle on the hospital and its specialists, he would lose practically everything he valued, his medical practice, his family, and his home."
(4) "The supply of medical resources, rather than the underlying needs of patients, is determining how much medical care they get."
(5) "How is it that a dangerous, highly experimental treatment came to be given to thousands of women before it had been adequately tested?"
(6) "Even as the number of [medical] imaging tests [X-ray, CT, MRI] is going up, numerous studies suggest that all those pictures are not nearly as effective at improving diagnosis as many doctors--and patients--tend to think."
(7) "On Thursday, three weeks after Justin swallowed his first antidepressant [prescribed to him by a university doctor], his roommate walked into their apartment to find his friend dead [of suicide]."
(8) "The drug company representative, or drug rep, usually [is] a handsome young man or shapely young woman who has been recruited more for his or her good looks and outgoing personality than for his or her aptitude for science or medicine."
(9) "The more specialists involved in your health, the more likely it is that you will suffer from a medical error, that you will be given care you don't need and be harmed by it."
(10) "The Institute of Medicine estimates that only 4 percent of treatments and tests are backed up by strong scientific evidence; more than half have very weak evidence or none."

Finally, if you want to seriously investigate this topic more, I recommend two classic books:

(1) "Confessions of a Medical Heretic" by an American doctor.
(2) "The Medical Mafia" by a French-Canadian doctor. (This conscientious doctor lost her medical license for having written this book.)

In conclusion, if your satisfied with the medical system, then there is no reason to read this book. But if you're not and what to protect yourself and your loved ones, then read this well-researched book and prepared to be stunned!!

(first published 2007; introduction; 10 chapters; main narrative 305 pages; acknowledgements; notes; index; a note on the author)

<<Stephen Pletko, London, Ontario, Canada>>

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on December 4, 2007
This is an extremely important book to read for anyone who has or will come into contact with the healthcare industry - that is pretty much every single person alive in the USA. The current health care system is broken very badly. The media and politicians talk about it but not enough. The problem is far more serious than any national issue. The US spends over 15% of its GDP per capita on health care which is by far the greatest amount compared to other nations. What do we get for it? According to WHO the our outcomes are roughly comparable to Chile (worse than Greece). For outcomes, I am using "Life expectancy at birth", "Healthy life expectancy at birth", and "Probability of dying between 15 and 60 years". (See [...] Chile spends only about 6% of their GDP on healthcare. There are lots of reasons for this poor performance but Brownlee discusses one that is rarely talked about which happens to be the most important reason. That reason is overtreating.

Brownlee has done her research very well and presents a well balanced (until the last chapter but more on that later) account of why our current system leads to overtreating. She discusses the three main reasons as being 1) fear of malpractice law suits by physicians (ie: doctor orders head CT scan for a patient with a headache even though chances of brain tumor is very small). The second reason is consumer demand (ie: patients demanding unnecessary tests) and finally financial incentives and culture in medicine (From early on medical students are taught to gain as much information as possible hence leading to unnecessary tests and procedures). All 3 reasons are valid. Perhaps Brownlee underestimates the importance of the first two reasons.

The reason I gave this book 4 stars instead of 5 was because of my disappointment at the final chapter. In the final chapter she proposes some solutions. Throughout the book I was excited to hear her solutions. Given her insights and brilliant research, I expected well thought of solutions with solid backing. She basically proposes copying the VHA (Veterans Health Administration) or HMO's like Group Health. She also touts electronic record keeping. She ignores the problems that will undoubtedly arise from the proliferation of these systems. For example, she states that under the current system physicians have perverse financial incentives to perform procedures since they get paid for each procedure. Under a system, where physicians are salaried like Group Health or VHA, physicians would have perverse incentives NOT to do appropriate procedures. Why would that system not lead to undertreating? Furthermore she begrudges drug companies like Pfizer for having gross margins of 27%, considerably higher than GE and Walmart. One cannot compare a drug company's single financial stats with another company in a different industry. Brownlee ought to know that better. Had she used gross profit then both GE and Walmart would have profits more than twice Pfizer's. In any case it should not be the government's job to keep track of companies' profitability in a capitalistic system.

In all fairness to Brownlee, US Healthcare system is very complicated and perhaps she should not have tackled solutions at this point. I look forward to a sequel where she has more thoughtful solutions with solid microeconomic foundations. In any case, this is a must read and she has done an excellent job (until the final chapter).
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on March 24, 2008
This book was also well-written. It is about medical treatment in the U.S. today, with attention to both providers and patients. It could have been much shorter, but the author gives the personal side of medicine and delves into many details. The approach leans to anecdotal. It tells how providers over-treat and over-prescribe because there are monetary incentives to do so -- from insurers, Medicare and Medicaid. It tells how patients, often armed with info obtained from the Internet, demand too much because they are insulated from the cost, often wanting more expensive and new but less effective treatments. The combination makes it a "supply-driven" market, in which what the providers have and know outweigh focus on the patient and the most effective treatment in the longer term. It tells about the frequent occurrence of errors with drugs and in hospitals. Treatment of patients tends to be uncoordinated by providers and there is a lack of use of patient-focused information technology. There is too much reliance on specialists and too little on primary care physicians.

There is extensive coverage of the overuse of cardiac surgery and the era of high-dose chemotherapy with bone marrow transplant for women with breast cancer. The latter was a brutal process for the patient, with little improvement in outcomes, and very expensive. It covers spinal fusions. The reader will hear about how drugs are marketed and how and why they are prescribed. It covers the impact HMOs have had on medical practice.

She compares the U.S. to other countries. Less is spent on medical care in other countries, but patients don't expect as much and have much less access to expensive and experimental treatment.

I will point out one flaw. It's understandable the author makes it, since finance is not her expertise. Near the end she compares percent return on sales of Pfizer, General Electric and Wal-Mart. This implies Pfizer is many more times profitable than Wal-Mart. It is very misleading because these are much different types of business, with far different rates of inventory turnover and research and development costs. A much better comparison is return on equity. For the latest five years on this basis Wal-Mart was 1.7 times as profitable as Pfizer.
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on October 28, 2007
This well-written book is easy to read and raises some big questions about what we really want from our health care system. The author has obviously done a lot of research and looks at the history of how we got here, but she also brings it all to life with lots of stories and real examples. I'm a nurse, but I learned new things from reading this and found that it gave me some new perspectives on my work and the experiences of my patients. Definitely recommend it to anyone concerned about the cost and quality of our American health care system.
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on August 16, 2008
The author clearly documents how our healthcare system frequently wastes resources on unnecessary scans and procedures due to a number of reasons including, demands of the patient, doctor's personal beliefs in a procedure, and the economic incentive of more procedures resulting in more profit.

From the author's perspective, over treatment is the problem and the solution is better assessments of what scans and treatments are needed, part of which includes communication between the doctor and patient. When the patient understands and can weigh the potential risks and benefits, he or she is likely to be more conservative than the doctor, resulting in less care by direction of the patient.

What the author overlooks is the patient's lack of consideration of cost. In nearly any other transaction in our economy, the customer would not only evaluate risk and benefit but also cost. Over treatment is not the core problem, but a symptom of the problem. The problem is our healthcare system is a big all you can eat buffet where your personal consumption has little or no impact on your cost. As the community eats more and more, the buffet price goes up for everyone. Meanwhile the cooks are profit motivated for you to eat more. The expensive dishes are being promoted while the cheaper ones may not even be displayed unless you ask for them by name.

Pharmaceutical companies, medical device manufacturers, hospitals and physicians need to have the same market pressures that nearly every other business has, that their product or service be affordable to their customer and it's benefits outweigh it's cost, otherwise there will be no sale and thus no profit. Insurance works against this basic virtue of the free market. A system that gives the customer an incentive to shop and consider costs, such as HSA's, is what is truly missing from America's healthcare system. Over treatment is merely a symptom of the underlying problem.
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on April 1, 2008
Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive.

Patients with the same illness are getting more costly medical care in certain parts of the country but actually do worse. The amount of medical care delivered is driven by the number of specialists, hospitals, and technology available in the community. The more doctors and hospitals add new services and technology the more likely those expensive services are used regardless of whether patients need it but because the providers can get paid for it. When organizations and committees try to set up guidelines or do research to see if current therapies are effective, special interests and politics kills the initiatives.

Hospitals focus on generating more business in departments which are profitable, like oncology, with newer buildings and the latest medical equipment so that they can afford to run emergency departments which continually lose money. Doctors and patients are enamored with the latest treatments and interventions which often are far more expensive, aren't better than existing therapies, and like the case of bone marrow transplant for metastatic breast cancer patients, are more lethal.

The pharmaceutical industry is intimately linked to doctor education and invariably influences which prescriptions are prescribed and market prescription medications as easily as consumer companies promote common household products. It is money not science that drives the healthcare system.

The author believes that solving the dysfunctional healthcare system requires that doctors and hospitals align themselves into integrated healthcare organizations like the Mayo Clinic, Kaiser Permanente, and the Veterans Health Administration. Unfortunately, however, because she makes such a compelling case of how each of the various providers and businesses each have a financial self interest to keep the current system going at the detriment of patient care, it is difficult to see how the transition will occur, if ever.

If you were asked to set policy for the White House, then this would be the book to get you up to speed on what makes our healthcare system the most expensive in the world and the worst at keeping us healthy. If however you are just trying to navigate through our healthcare system then the book Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System would be a better bet.
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HALL OF FAMEon November 21, 2007
Politicians constantly tell us we have the best health care in the world. Yet, our life expectancy lags that of other developed countries, and a recent study of heart attack patients found Canadians did just as well as Americans - despite spending far less than we do. Waiting for elective surgery or an MRI in other developed nations doesn't account for the difference in spending - the 15 procedures and tests accounting for the vast majority of waiting in other nations only account for 3% of costs in the U.S.

Brownlee goes on to say we devote nearly 33% of spending to administrative costs and profits (I suspect she is high - other sources limit this figure to for-profit health care) - while failing to provide insurance for nearly 50 million, vs. 16% for administrative costs in Canada, which covers everyone. The average cost/day in a U.S. hospital is 4 times the average in the rest of the developed world. The biggest issue, however, is that between 20 and 33% is spent on unneeded care (per a widely quoted study) that often harms the patient (eg. needless radiation, infections).

Why so much extra treatment? Lack of information, a system that pays more for doing more, and cutting back on care smacks of rationing and an overemphasis on economy. Probably the biggest factor, however, is that supply creates demand in health care (Roemer's Law) - the more technology, hospital beds, and specialists available, the more they will be used, and the higher costs will rise. On the other hand, most major surgeries hardly vary between regions - eg. colon cancer, hernia repair; these are the the problem.

Legislation that doubled the number of medical school graduates (especially the number of specialists) between '60 and '80 assumed this would lower costs. Instead, utilization of expensive technology and procedures increased; meanwhile, Medicare reduced or eliminated the incentive to hold down prices, especially for those with limited funds. Regions with fewer specialists and more primary care physicians have better overall health.

Consumer-driven health plans (including health savings accounts) make the absurd assumption (per some health care experts) that patients or their families will monitor and make decisions about their own care when in the hospital - even when a family member is a physician. There is too much practice variation, too many hand-offs between specialists, and too much missing information - eg. drug companies withholding or providing misleading information, and a dearth of randomized clinical trials to scientifically evaluate various alternatives (one expert estimates only 15% of medicine is backed by such research, and that much "research" is seriously flawed - eg. selection bias).

Malpractice fears doe not explain high costs of medicine either - comparisons between states with limitations vs. those without find only a 15% difference in unneeded tests.

One major concern with "Overtreated" is that I suspect its estimates of excess costs and deaths are overstated. Examples include the previously referenced instance of overhead costs in the U.S., and the estimates for deaths caused by errors - eg. the 80,000 quoted in the well-known Institutes of Medicine, PLUS another 400,000 for drug errors, PLUS thousands more for excessive chemotherapy administered to breast-cancer patients, etc. However, the book's basic assertions are soundly backed up.
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on October 8, 2012
My husband, ER physician Dr. Bob Pollard, has been immersed in this issue for 30 years. This is his favorite healthcare book EVER because it pinpoints exactly what is wrong, and how our current insurance run healthcare system perversely incentivizes physicians to prescribe too many drugs and do too many procedures. And it punishes doctors like him, who want to carefully analyze what will really help patients the most.
So often he feels he is the only physician saying this, so its a relief to see that others can see the big picture.
We are thankful that Shannon Brownlee is working in this direction at national policy level. Thank you Shannon!!!Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer
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