Online Extra: When More Medicine Is Less

A Dartmouth study finds a greater risk of death among patients treated in high-cost hospitals and clinics -- and highlights conflicts of interest

By John Carey

Getting more medical care, and paying more for it, can actually make your health worse. That's the paradoxical conclusion of Dartmouth Medical School's Dr. Elliot S. Fisher. He found that the amount spent per person on health care varies dramatically in different parts of the country. Southern California is high cost, for instance, while Northern California is low cost. Spending is high in the Boston area, and low in Western Massachusetts and Minnesota.

Fisher originally expected to find that people in areas with more healthcare would be healthier and longer-lived. The opposite was true. "If anything, it looks like there is a substantially increased risk of death if cared for in high-cost systems," he says. The reason: The additional tests and procedures in the high-cost areas bring more risks than benefits. "A large portion of those extra costs are due just to proximity to health care," says George Bennett, CEO of Health Dialog Analytic Solutions, which tries to get unbiased information to patients. "Not all those expenditures are optimal or even appropriate."

Why does this happen? Clearly, one huge underlying cause is money. The way the U.S. health-care system is structured offers doctors, hospitals, and companies enormous financial incentives to provide more and more care. Surgeons will get paid if they do a bypass operations, insert ear tubes in children, or take out a prostate. If they recommend waiting or doing drug therapy instead, there's no payday.

"You get paid for operating and not paid for not operating," says Dr. Jack Paradise, a professor of pediatrics and otolaryngology at the Pittsburgh School of Medicine and Children's Hospital of Pittsburgh. "Conflict of interest is hard to rule out."

POTENTIAL CONFLICTS.

  Similarly, hospitals get higher revenues if they put more patients in their new catheter labs or operating rooms. This isn't to say financial considerations outweigh medical choices. But studies have shown wide variations in the amount of care among hospitals -- and again, more care doesn't bring better results.

Researchers at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School have looked in detail at what happens in the last six months of life at 77 top hospitals in the U.S. The results were startling: The average number of days spent in the hospital during the last six months of life was 10.1 days at Stanford University hospital compared to 27.1 days at New York University Medical Center. The average number of doctors visits ranged from 17.6 to 76.2, with NYU at the top.

Yet there's no evidence that the more intensive care brings better outcomes or quality of life. In fact, the researchers suggest, the opposite is true. "The problem is not underuse in low-rate regions and hospitals, but overuse and inefficiency in high-rate regions," concludes Dr. John E. Wennberg, professor of medicine and director of Dartmouth's Center for the Evaluative Clinical Sciences.

The potential conflicts of interest are even starker with drug and medical device makers. The pharmaceutical and device industries are, after all, businesses. Like any businesses, they would be remiss in their duty to shareholders if they didn't try to sell as many of their products as possible.

GOVERNMENT CONCERN.

  Health care is different from, say, selling cars. No one is hurt if people buy one car over another, or more cars than they need. But for all their benefits, drugs have dangers. Taking the wrong one, or the wrong combination, or too high a dose, or one that's not needed, does hurt people -- and raises health care costs unnecessarily.

That's why the Food & Drug Administration puts curbs on the marketing practices of companies. But because of the huge amounts of money that come with increased sales, they have every incentive to push the envelope when it comes to marketing. As a result, they often work to turn ordinary conditions, like jittery legs, into "diseases" that need treatment (see BW Online, 05/08/06, "Hey, You Don't Look So Good").

They woo doctors with free samples, gifts, trips, and other enticements to prescribe more drugs and use additional devices. A recent lawsuit, for instance, accuses Medtronic (MDT ) of handing hundreds of thousands of dollars for minimal work to prominent back surgeons who are in a position to boost use of the company's spinal-implants. Medtronic spokesman Rob Clark notes that these are allegations. "We do not tolerate any kind of conduct that is unethical...or violate the law," he says.

BOTTOM-LINE BIAS.

 In another case, Warner-Lambert, a part of Pfizer, (PFE ) was ordered to pay $430 million after pleading guilty to charges of illegally marketing its epilepsy drug, Neurontin, for unapproved uses. The company aggressively pushed the drug for conditions like bipolar disorder, back pain, and headache -- for which there was little or no evidence of effectiveness.

The marketing campaigns, which included trips and big "speaker" fees to doctors, turned the drug into a blockbuster, with billions of dollars in sales per year. But while the practices fattened the company's bottom line, many patients may have been hurt by unnecessary use of the drug, which lawsuits allege can cause suicidal thoughts, tumors, and convulsions.

These powerful financial incentives make it that much harder to get the right treatments and the right amount of care to Americans.

Carey is a senior correspondent for BusinessWeek in Washington

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