MedSmarts

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America’s Health Scare System

Fear is the Answer

What’s the question? What is it that’s driving our healthcare spending over a cliff – literally threatening to bankrupt the country and its citizenry?

The answer is fear. Fear is a major driver of America’s healthcare spending crisis. And if you don’t think it’s a crisis – picture yourself paying three times your current healthcare costs in ten years or less.

This isn’t a reach. They already increased by two-and-a-half times over the past ten years – and that was before the baby boomers reached their retirement years and start spending big-time on health care.

The average American family’s total healthcare costs – that’s insurance premiums and out-of-pocket costs combined – exceeded $20,000 in 2011. That means a tripling would add about $40,000 a year to your annual healthcare spending – and your employer is unlikely to pick up much of that.

In fact, many employers – up to half surveyed – are expected to drop health insurance coverage altogether once healthcare reform takes full effect in 2014. Now there’s something else to fear.

So if all this health-related fear hasn’t hit you in the pocketbook yet, it soon will.

Should You Fear Fear?

FDR is famously remembered for his State of the Union quote that “The only thing we have to fear is fear itself”.  Little could he imagine how applicable that might be to his fellow Americans’ healthcare some eight decades later.

It won’t help any to increase your fear or anxiety, but it will help to understand how fear drives so much of our poor medical decision-making. By doing so, you may be motivated to find ways to manage your medical fears rather than give in to the knee-jerk responses – like over-reacting with overly aggressive treatments for minor medical concerns – that are responsible for so much of our current healthcare misspending.

Consider this example from MedSmart Patients: more women with breast calcium deposits that may represent an early form of suspected breast cancer called ductal carcinoma in situ (DCIS) are choosing the most aggressive treatment possible (double mastectomy) to prevent their DCIS from progressing to full-blown breast cancer.

It’s important to understand a few things about this – and they’re not all about dollars-and-cents:

  • There’s considerable medical debate about whether DCIS even constitutes cancer or merely another abnormality that may or may not progress to cancer – similar to indolent prostate cancers that many doctors consider “pseudo-disease”;

  • Radical mastectomy has not been shown to be any more effective at preventing cancer progression than more conservative breast conservation therapies – generally lumpectomy and radiation therapy – that have dramatically improved over the years;

  • Double mastectomies leave many women with extensive nerve damage requiring a lifetime of pain medications that themselves may cause an early death, conceivably sooner than the suspected breast cancer that may never have progressed to actual breast cancer; and

  • Even these patients’ surgeons – with a vested financial interest in performing more surgeries – were less aggressive in recommending double mastectomies than when women themselves made their treatment choice without physician input.

WHAT?

Folks, our surgeons are not known for their reluctance to perform surgery; it’s how they earn their substantial incomes – much of it often inflated by marginal and unnecessary surgeries (see Our Healthcare Sucks for examples and more on this).

When patients are even more aggressive than their surgeons, it tells us something’s amiss. What’s amiss here is fear – overblown overreaction that’s representative of how much fear drives our healthcare choices.

Is this fear unfounded?

Sometimes it is – hypochondria being the obvious example. But usually there’s a real basis for our fears – DCIS isn’t something to just blow off, after all.

Oftentimes, however, there’s less basis for our medical fears than we imagine. Think cholesterol, for example. Many of us take cholesterol-lowering statin drugs like Lipitor and Crestor based on flawed assumptions about the importance of cholesterol in heart disease.

Cholesterol reduction has been proven effective for those who’ve already had a heart attack or stroke and some other advanced heart disease. But it’s effectiveness for those who haven’t experienced these acute conditions is hotly debated in medical circles. There’s an ongoing debate among doctors about the entire cholesterol thesis – at least for otherwise healthy people with no history of heart disease – with emerging evidence that stem cells may be more important for cardiovascular disease progression than cholesterol.

There’s also debate about what represents elevated cholesterol, with many experts suggesting the threshold for considering medications isn’t the 200 mg/dL many physicians still employ, but 240 – and over 300 for patients 65 and older. Yet many Americans are prescribed statin drugs with cholesterol levels well below these thresholds – and increasingly even below the 200 mg/dL level in the name of “prevention”.

Is this really a good idea? It might be – if this and other treatments were risk-free. But they’re not…

Fear the Treatment As Much As the “Disease”?

The older you get, the less of a threat higher cholesterol readings are to your health – and the more of a threat cholesterol-lowering drugs are to your health.

But the ongoing fear-a-thon over cholesterol will persist because so many are wed to this thinking – and because of significant financial incentives on many fronts to perpetuate it.

But where’s the fear of type 2 diabetes that statin drugs used to lower cholesterol have been shown to increase? Many doctors will tell you that risk is real, but it’s outweighed by the cardiovascular benefits of taking these drugs. And for some patients, this is true. But for many patients – an increasing proportion as their use is spread to healthy patients with no history of cardiovascular disease – it may not be true.

And the risks increase with age because older livers and kidneys are less efficient at removing the chemical buildup of drugs in the bloodstream, leaving older patients at greater risk for negative drug reactions and interactions. And the more drugs they’re taking, the greater the risk.

Ignorance Ain’t Bliss

The excellent resource Worst Pills, Best Pills cites a test of doctors for their knowledge of the special drug requirements of older patients in which fully 70% of doctors flunked. So relying on your doctor to be aware of the added risks with older patients is unlikely to be rewarded with anything but treatment injury and inflated medical bills to treat it.

Muscle pain and weakness is a well-known side-effect of statin drugs and the primary reason many patients abandon their statin regimens in six months or less. Sometimes this is a bad idea, especially if it’s after a heart attack or stroke.

But statins are still often prescribed for heart failure patients – whether they’ve had a heart attack or not – despite there being no good evidence that they help with heart failure. Indeed, the heart is your body’s biggest muscle, and statins cause muscle weakness for many patients. They’ve also been associated in studies with increased shortness of breath during exercise by heart failure patients, making them counter-productive.

Meantime, fully a third of heart failure patients in America aren’t receiving blood-pressure lowering drugs called ACE-Inhibitors that have been proven most effective for heart failure.

Fewer still take advantage of fish oil, the herb astragalus or infrared sauna treatments – all shown to improve results in heart failure patients with little risk, if any, of harm – despite the lack of good conventional medical treatments for heart failure. This is due to both medical intransigence and the fact that they’re not covered by health insurance.

Yet according to one researcher, Dr. Donna Arnett:

“Heart failure has a shorter life expectancy than almost every cancer with the exception of…pancreatic…Heart failure is one of those conditions that’s really lethal.”[i]

Most heart failure patients – a patient population that’s growing dramatically due to rampant obesity and more heart attack survivors – don’t panic about dying from their heart failure like many cancer patients do, even though their risk for doing so may be even greater.

But they are like many cancer patients when they accept medications that may do them more harm than good – although their treatments aren’t inherently-toxic like most conventional cancer treatments that may shorten rather than extend the lives of vulnerable cancer patients.

Be Careful What You Wish For

The most dramatic evidence that intensive medical interventions may shorten rather than extend patients’ lives is discussed in our free report “Death-by-ICU: End-of-Life Care in America“. It discusses a study at Massachusetts General Hospital that found that advanced lung cancer patients who rejected intensive end-of-life treatments actually lived 33% longer, or about three months longer than those who chose the most intensive treatments possible.

This isn’t really shocking when you think about it. Common sense tells you that frail patients nearing the end of their lives are likely to incur disproportionate harm and injury from the major trauma of aggressive invasive procedures.

It’s understandable that desperate people often resort to desperate measures – but this is where their doctors are supposed to intervene and prevent them from doing things that will harm them more than help them.

So why don’t they? It’s part of their Hippocratic Oath to “Do no harm” and embodied in every medical code of ethics, after all.

There are lots of explanations. Doctors often want to appease anxious patients by doing something even when watchful waiting is the more prudent course. They’re also financially incentivized to perform or order treatments – whether indirectly by shortening office visit times by shuttling complex cases off to specialists, or directly in the case of specialists who profit by performing tests and procedures.

Whatever the explanations, they’re often doing their patients a grave disservice.

 Fear-Mongering?

Pharmaceutical companies have long been accused of  “disease-mongering” by inventing “diseases” for their medications to treat – solutions in search of a problem.

What we find in our healthcare system now is pervasive fear-mongering.

Patients without heart disease fear high cholesterol more than they need to and don’t fear their cholesterol-lowering drugs nearly enough. Late stage cancer patients fear dying so much they agree to extreme treatments that are likely to cause them to die even sooner.

This is generally true across the board. We fear suspected disease too much and aggressive medical treatments too little.

It’s not possible to calculate with any precision how much of our healthcare misspending is attributable to our exaggerated fears. But other developed countries spend a lot less on their healthcare and have generally better results. The hypotheseis here is that patients in those countries are also less likely to demand instant gratification for every suspect condition, ache, or pain. Their superior results may have more to do with the treatments they avoid than those they receive.

In a future where you and your family will pay for more of our healthcare misspending yourselves – and few will be able to afford  another forty grand a year in medical spending  – it’s time we get a grip on our fears. And learn to respect our medical treatments for the harm, as well as the good, they may cause us and our loved ones.


[i] Drugs, money, and glory: Is cancer beating cardiovascular disease? Part 1. HeartWire. theheart.org. 8/11/11.

 

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