A “Prequel” to Health Care Reform

Reader Jim Jaffe has written an excellent “prequel” to healthcare reform here.

He explains how we got where we are, and how and why the huge problem of over treatment was ignored for so long. 

Readers who are relatively new to HealthBeat may find this background particularly helpful, especially if you are not sure what I or other readers are talking about when we talk about over treatment as the big problem, or refer to “the Dartmouth Research,” or the fact that “higher quality and lower spending go hand in hand.” (For example, as Jim points out, the Mayo Clinic offers higher quality care than many other hospitals, at a lower price. Patients undergo fewer tests and treatments, see fewer specialists and
both outcomes and patient satisfaction are higher. )

Anyone who reads HealthBeat will, I think, find something valuable in Jim’s post.

30 thoughts on “A “Prequel” to Health Care Reform

  1. His prequel is too focused on health care waste – which is a problem, but by no means the whole problem. We could solve waste and still have a lot of uninsured, a lot of too-expensive medicines, and a lot of sick people suffering needlessly; let’s all hope Obama’s team stops waste, but doesn’t stop there. Worse yet, Jaffe seems to give Betsy McCaughey credence as a serious commentator, which makes the rest of his views suspect.

  2. Duncan–
    More than two decades of Dartmouth reserach reveals that the waste Jim talks about accounts for #1 out of every $3 that we, as a nation, spend on healthcare. (see http://www.dartmouthatlas.org)
    That waste takes the form of unncessary hospitaliations, redundant tests that often provide no benefit to the patient, unncessary, often unproven procedures and over-priced drugs and devices that are no more effective than the products they are trying to replace–and often, much riskier.
    This isn’t just a waste of money–it’s hazardous waste. Overtreatment hurts people.
    Health now accoutns for over 17% of GDP. If we spend much more, we begin to crowd out other priorities: spending on education, the environment, secruity, global warming, helping the unemployoed, etc.
    We cannot afford to cover all of the uninsured and underinsured unless we simultaneously cut out the waste. This is what President Obama has been saying–repeatedly.
    I know Jaffe; he isn’t giving McCaughey credence.

  3. It seems awfully hard to imagine how you can change physician behaviour given the complexity of health care. Imagine an elderly patient with mild gastritis and viral cold, she was seen and discharged appropriately with an acid pill and cough syrup. Still had some cough so went to different E.R over weekend, got admitted, seen Gastroenterlogy for gastritis( normal findings) though no signs of bleeding, got more xrays,placed on antibiotics( no sign of infection), totally decompensated while bed ridden in the hospital. Could not be discharged safely, so ended up in nursing home for rehab. Nothing in her work up showed she had bleeding or a brewing infection. How can you pin this down? The second scenerio brings in more $$$ with worse outcomes. The providers at the different hospitals did not even communicate regarding what was already done to avoid duplication. Even if the patient later realized much of the care was unnecessary,they really don’t care as long as they don’t have to foot the bill.

  4. You’re right, it is a good post. I don’t understand what’s to debate. General Motors came to the same conclusion (Google Sam Shalaby Detroit News) and tried to work with hospitals in their region of the US to work more efficiently. One ground-breaking idea GM’s engineers came up with was to move the radiology dept closer to the ER…since almost everybody coming in the ER needs Xrays and needs em quick. That’s how earth-shattering complicated this is. GM couldn’t figure out why (upon reviewing medical bills) 2 patients in 2 different states with exactly the same condition had two remarkably different courses of treatment with a price discrepancy of forty thousand dollars. Stuff like that. There’s an advocate pushing for jaundice testing in every newborn. I don’t remember all the facts and figures but as I recall testing for jaundice is cheap and quick and cheaper than treating jaundice after it goes unchecked and leads to something else. A few hospitals (I think in Colorado) actually adopted this practice but last I heard the AMA fought her tooth and nail and rallied against what a terrible idea it is to test every newborn baby for jaundice.
    Y’know, as far as I’m concerned this is all we’re talking about. Common sense.

  5. In her book Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer (which was named by the NY Times as the best economics book of 2007), Shannon Brownlee imparts a broad and deep understanding of the Dartmouth Atlas research and its implications for the healthcare system as a whole, as well as for the safety and well-being of patients who are overtreated and undertreated. I recommend Overtreated as important reading for every person in the US.

  6. I’d hardly take advice from GM regarding efficiency. What a joke to even suggest they know a damn thing about healthcare. They cant even run their own industry, much less somebody else’s.
    ERs already have a dedicated stand alone x-ray and CT scanner, its absolutely ridiculous to suggest moving the ENTIRE RADIOLOGY dept, which includes 3-4 MRI scanners (which cost a few hundred thousand to re-site since you need a copper coated, magnetically sealed room), 10-12 x-ray machines, 6-7 CT scanners, 2 PET scanners, 1 SPECT scanner, a gamma knife, and a bunch of other misc nuclear imagers. Guess what happens when you move that stuff to the ER? You get MORE useless scans. ER doc says “hey this pt is coming in for abd pain and was dx with cancer 7 years ago. We got a PET scanner next door and its been a couple years since he’s had one, so lets just get one now so he can take it to his next oncology appt.” Then when the pt gets to the onc appt, the oncologist decides its a useless scan or he REPEATS it because the dumbass ER docs didnt optimize the scan appropriately.
    You see, its really not as simple as moving radiology to the ER.

  7. last I heard the AMA fought her tooth and nail and rallied against what a terrible idea it is to test every newborn baby for jaundice.
    Y’know, as far as I’m concerned this is all we’re talking about. Common sense.
    Uhh you’re conjuring this out of thin air. I’d like a link please.
    As it stands though, its interesting you picked neonatal jaundice to rail on. Do you have ANY IDEA how high the number needed to test and number needed to treat is in order to prevent one case of neonatal kernicterus? Its in the hundreds of thousands and meanwhile you spend millions of dollars on blood tests and phototherapy testing for high bilirubin levels that mean NOTHING about 99.99% of the time.
    In other words, its not a good cost/benefit ratio. It would be similar to doing a bone marrow biopsy on every 2 year old in the united states in order to supposedly catch a few extra cases of AML that you wouldnt have already diagnosed thru other means.

  8. I’m glad that Jaffe mentioned Peter Orszag’s report; Orszag is one policy wonk who is not afraid to go where the data lead him.
    There’s nothing wrong with “cookbook medicine”; in fact, it should be used more. Recipes are nothing more than algorithms; we use kitchen-tested recipes when we want to ensure high quality, consistent outcomes for our chocolate cakes. Medical professionals use algorithms all the time in their practice, and are taught to apply that reasoning to the care they provide to guarantee the intended patient outcomes. We may choose to “wing it” without a recipe in the interest of improvisation and creativity when cooking; but providing medical care is no time to “wing it”.
    However, the “government” is not the agent “telling” doctors and hospitals how to treat their patients, and this is not a “logical conclusion” (per Jaffe). Guidelines for evidence-based practice in each specialty are developed by the medical community based on their consensus understanding of the research. Just because they happen to be published on AHRQ’s web site as a central clearinghouse doesn’t mean that the “government” is “telling” clinicians how to practice.
    Jaffe’s determination that the right wing’s propaganda is a “logical conclusion” reveals the weakness in the belief that it’s possible to develop policies from the “center.” It’s not. Different sides frame the issues differently, and it’s necessary to understand their respective frames in order to determine where they don’t line up, and their relative value in terms of the desired outcomes. It may be possible to work toward consensus on the final form of a policy, but Jaffe’s quest to find “the center” is futile and only leads to the lowest common denominator, IMHO.

  9. Maggie – I’ll trust you that Jaffe isn’t a McCaughey apologist, and stipulate that I don’t disagree with anything you’ve said. Yes – waste and overtreatment are huge parts of the problem, maybe even most of the problem. But my point still stands: we could solve the waste problem and still not have a just, functional health care system. There are about a million ways to create a highly efficient, wholly inequitable health care system – which wouldn’t solve any of the most vulnerable persons’ problems.
    So I still think a “prelude” to health care reform ought to go back further than the Dartmouth Atlas. Why does our system generate so much waste? How did we get that system in the first place? Is that waste at all related to the gross inequities of the current system? Those are the sorts of things I would be interested in reading more about, and the sorts of things that Mr. Jaffe doesn’t cover.

  10. This was a good way to get one’s toes wet in the issues of over-utilization and treatment variation.
    I do take issue with the following section:
    “Some politicians believe that patients could drive this change if they were spending more of their own money on care and not totally insulated by insurance, but such consumer-driven efforts have made little progress. In the 1990s managed care efforts in this direction were rejected, perceived as insensitive strategies to save money by compromising care.
    While the media was slow to pick up on the idea that the system was doing a lot more than needed to be done, journalists unsurprisingly found dramatic stories of patients denied needed care more compelling.”
    There is one mistake and one missed connection here:
    1. Managed care was not pursuing cost sharing in the 90s. Precisely the opposite. The share of out-of-pocket expenditures plunged in the 90s as the HMO “revolution” swept in. Cost-sharing became a common strategy around 1999 after the backlash when managed care companies retreated from utilization management techniques and needed another way to reduce the employer’s premium expenditure.
    This correction is important because:
    2. The reason that it was “unsurprising” that journalists have been slow to present stories on the value of care problem and instead focus on dramatic incidents of denials of care is that the backlash of the 90s generated a pre-set storyline: HMOs are evil and profit by denying care. Therefore, every care denial is not just a tragedy, but a cynical move by a corporation profiting on suffering and death. Forget the possibility that the treatment the sick person “needs” is unproven and a huge waste of money. The public didn’t want to hear that, because they were conditioned to believe that every chance was worth taking, and the rejection of that chance was based on cruelty and greed. That story is still ingrained in the public imagination, and it is a huge barrier to overcome. But we must overcome it if we are to succeed in reform, because so long as the public credulously responds to the provider lobby’s cries of “they’re preventing me from saving lives!” or “they’re forcing me to lay off health care workers this community needs!” rather than looking at the data about effectiveness and understanding how incentives can pervert the practice of medicine, efforts at major reforms will fail.
    In some ways, progressives are victims of their own success. They attacked managed care for so long and so hard in the name of universal health care (especially single payer) that they created a public perception that rationing of care or basing covered services on risk/reward/cost tradeoffs was unnecessary.
    As a result, America is ready for universal health care but it is not ready for reforms to how care is delivered and paid for to make it provide better value.

  11. As someone who counts himself a progressive, I should add: progressives of course played only a helping role. They didn’t “create” the unrealistic (indulgent) attitude towards care, only helped nurture it along with a media bent on sensationalism and an American tendency to refuse to accept death, among other things.

  12. Anon305 I don’t conjure up anything from thin air or Google links, they come straight from the horse’s mouths. I will ask said mouth to post exactly what she went through with the AMA and jaundice testing right here on this blog since you’re too unsure of yourself to supply your identity or email address. GM knows a lot more about the health care industry than, say, you do.

  13. Anon-By the way, how on EARTH would you know test results are “meaningless 99.9% of the time.” We don’t test every newborn baby so you have no idea what the statistics of test results would be for tests that aren’t being done. Who’s conjuring out of thin air?

  14. beyond thanking Maggie for bringing y’all into this conversation, I’d like to make two basic points.
    First is that I plead guilty to being a centrist. It is no accident that the prequel was posted to CenteredPolitics.com, a site dedicated to the proposition, which I share, that lasting progress comes from the center. I think Medicare, Medicaid and SCHIP all support that proposition. They’re imperfect, but quite helpful.
    Second, I think the challenge of changing treatment behavior is absolutely central and that we should give some serious thought about how to respond to conservative criticism about limiting choices. Knowing the right thing to do and actually doing it are very different things, especially when money and habit intrude. I’ve always found the “we report, you decide” attitude of the Dartmouth materials a bit problematic. I’ve yet to detect any change in behavior that resulted from their findings, however dramatic the data. The key to reform is getting folks to do the right thing.
    So when Orszag and others call for research on what works, I’m all for it. But I also think we must acknowledge that the next step, translating the results into action, is the tough one. How do we get there?

  15. jd said:
    “In some ways, progressives are victims of their own success. They attacked managed care for so long and so hard in the name of universal health care (especially single payer) that they created a public perception that rationing of care or basing covered services on risk/reward/cost tradeoffs was unnecessary.”
    At the heart of reform will be what works in healthcare, when do you use it, and who gets access to it! With our current disjointed, non-universal, somewhat market-oriented system, there are/were many ways to thwart good value. Some of these ways may have thwarted bad value as well, but the public just did not trust the incentives. For example, in the mid to late 1990’s, the state I lived in passed a patient protection act to try and cover-up or stop the perceived abuses of managed care. I sat on a Dept. of Health group that was the final level of appeal for denied processes. Although this “outside of the managed care company” review may have been somewhat effective for medical necessity decisions, it mostly failed for 3 reasons that complicated the decisions. These reasons were:
    –Contractual language in the various managed care contracts that allowed even medically necessary processes to be denied as outside the contract language scope. Could patients realistically know this beforehand??
    –Political interference from the conservative governor’s office to back the HMO viewpoint.
    –ERISA federal exemption of self-insured plans that did not allow state insurance laws to apply.
    My point in writing this is to stress just how important it will be for fairness and actual intended results that the healthcare system evolve into a universal type system in the area of access and access to what!

  16. I stand corrected, it was the American Academy of Pediatrics, NOT the AMA that was against the jaundice testing. I don’t know if Sue will come here and post but there was an article in the Wal Street Journal on Feb 6 2007 by Rachel Zimmerman regarding this.

  17. “So when Orzag and others call for research on what works, I’m all for it. But I also think we must acknowledge that the next step, translating the results into action, is the tough one. How do we get there?”
    Jim,
    I think we need to get the incentives right and we need to improve our measurement techniques.
    I believe the easiest way to change the incentive structure is to change the payment policy. That means we need to either stop paying for services, tests and procedures that are not cost-effective or no better than less costly alternative approaches or at least expose the patient to much higher co-pays.
    What I have in mind for measurement includes the following:
    1. Track total utilization of healthcare resources at the individual patient level via a smart card like they do in Taiwan. There are probably people who over utilize the system for no good reason and some intervention in those cases would be appropriate, I think.
    2. Develop uniform methods for measuring hospital infection rates, readmission rates, etc. and publish the results in a user friendly format that is easily accessible by both patients and referring doctors.
    3. Publish surgical outcome statistics for both hospitals and surgeons, at least in a general sense with an attempt to risk adjust. Since small differences are often not statistically significant, I think something like: as expected, worse than expected or better than expected would be reasonable. Quite a few hospitals already do this.
    4. I also think it is important to develop the state of the art around individual risk scoring. Medical risk scores should reflect such variables as age, current health status, smoking and drinking habits, BMI, blood pressure, cholesterol level, family history of disease and socioeconomic status. We might be able to use existing FICO credit scores as a proxy for socioeconomic status.
    5. While it may be too difficult and unfair to measure and try to reward or penalize primary care doctors based on the health status of their patients, we might be able to determine whether some are using significantly more healthcare resources than others for similar groups of patients. By similar groups, I’m thinking of low and average risk elderly patients, low and average risk patients between 50 and 64, low and average risk patients between 18 and 49, low and average risk children and then high risk patients in the same age groups. We could factor socioeconomic status into the analysis by using the credit scores.
    6. Electronic medical records would be needed to gather all of this information as well as to, hopefully, reduce duplicate testing and adverse drug interactions and to learn more about the efficacy of various treatment approaches.
    CMS already adjusts payments to private insurers who participate in the Medicare Advantage program based on risk scores. Humana stated recently that its medical cost ratio for its high risk MA members is approximately the same as the MCR for HUM’s lower risk members. This suggests that CMS is on the right track though I suspect that there is lots of room for improvement in its risk scoring approach.
    If we are ever going to significantly reduce the waste of healthcare resources, it’s critical that we get the incentives right for doctors, hospitals and patients and that we develop ways to satisfactorily measure and reward or penalize the wise or wasteful use of healthcare resources. Risk scoring that takes into account all of the relevant factors, including socioeconomic status, that drive healthcare utilization is critical.

  18. To Jim Jaffe:
    1) Medicare/Medicaid were passed with no center in sight. When Johnson signed the bills, he said, “There goes the South for the Democrats.” (I think this is the correct quote)–and he was right.
    2) Re: changing treatment behavior based on DA research, or something like it: I believe that some states have begun different demo programs based on the recommended care guidelines. I don’t know the details or if they are ongoing or if they have any outcomes data, but Commonweath Fund has a section on their web site called “States in Action” with capsules about these programs. Also, CMS’s Hospital Compare website uses AHRQ’s quality indicators (http://www.cms.hhs.gov/HospitalQualityInits/11_HospitalCompare.asp) It’s not great yet, but it’s helpful. Also, CMS pays some providers for performance (using recommended practices, better patient outcomes), and doesn’t pay for “never events”.
    3) The UK’s NICE organization does exactly what you recommend and has been for several years; the key is that they are independent (http://www.nice.org.uk/). They also are able to have the NHS implement “best practices” faster than the 18 years it takes in the US (according to the IOM)to translate research into practice.
    4) The EU’s European Medicines Agency came up with guidelines for generic and branded biologicals a couple of years ago while the US healthcare industry is still trying to figure it out. (http://www.emea.europa.eu/htms/human/humanguidelines/biologicals.htm)
    Bottom line: It’s not true that we can’t figure it all out just because it “wasn’t invented here.”

  19. Why is the rampant fraud that has exponentially increased over the last 20 years never addressed?
    The fraud in our healthcare system is in the trillions of dollars?
    No one ever speaks of this.
    Why is that?

  20. I’m still not hearing anything in the reform discussions about addressing defensive medicine. Does anyone seriously think this doesn’t exist or that its cost is trivial?

  21. To ACarroll,
    History’s lessons are important, but not always obvious. Reading Caro or Taylor Branch makes it hard to see LBJ as a liberal. In fact, his remark about losing the south — which proved prescient and that period’s finally ending — was about the voting rights act, which was enacted with centrist support. you can find more on my lbj take at http://centeredpolitics.com/081114%20Jaffe%20LBJ.htm
    medicare and medicaid were centrist programs, that’s why there were two of them. medicare was like ss for middle-income whites with guaranteed benefits. medicaid was for poor, often non-white, with benefit package and funding determined by the states( read south, states rights). also the existing insurance reimbursement scheme was retained to buy support from less than liberal physicians.
    it is important to recall (http://www.huffingtonpost.com/jim-jaffe/obama-right-to-resist-lef_b_168825.html) that the Democratic majority in Congress has become more conservative as it has grown. and if you want it to grow further, it will probably grow a bit more conservative yet
    The folks at the top have the right ideas, but they’re cognizant of the need for compromise. Those looking to create a perfect system here will ultimately be disappointed and some at the fringe will want to walk away from the deal. that would be a very big mistake

  22. Jim is doing a great job of replying here so I haven’t felt a need to weigh in . . .
    But let me make a couple of comments:
    ACarroll– Yes “Overtreated” is very good.
    On professional societies setting guidelines for evidence-based treatment– that hasn’t worked out very well in many specialities: See the post “A Very Open Letter From an Onocoogist” . . . Urologists still recommend PSA testing and aggressive treatment for early stage prostate cancer–even though the American Cancder Socieyt and National Cancer Institute don’t; spine surgeons have resisted medical evidence about back surgery; heart surgeons have resisted (and tried to bury) medical evidence about bypasses and angioplasties . .
    This is why we need unbiased panels of reserachers and specialists sorting thorugh the comparative effectiveness reserach. MedPac has suggested that doctors who work on salary, not fee-for-service, would be less biased (because less concerned about volume). . .
    Gregg– When woudl I have time to Twitter??
    Thanks for the link to institutional memory.
    jd– Yes, journalists completely blew it when it came to managed care. They loved the sensational stories about “Care Denied” and ignored the fact that often, the care was denied for a good reason (it wouldn’t help the patient). And, as tyou say the media completely ignore the problem of overtreatment.
    The Dartmouth Research was out there. There were good arguments for “managing care” on quality–and refusing to pay for unncessary, unnproven, ineffective treatments.
    I wrote a cover story for New York Magazine at the beginning of the 1990s explaining how everything turned on whether HMOs managed care on quality or simply on price. I interviewed Paul Ellwood, the father of managed care-a very good man and doctor.
    I also wrote about managed care for Barron’s. At the time there were still a number of non-profit HMOs doing a very good job of managing care. Some still exist–and are continuing to succeed–in the Northwest.
    But for-profit HMOs drove most of them out of business.
    And at the time most New Yorkers rejected the idea out of hand. No one was going to say “no” to them.
    Everyone– Obama is putting the money into comparative effectiveness reserach for a reason. I think Medicare will give the reserach financial teeth by charging higher co-pays and paying lower fees for less effective treatments –and I susepct they will charge lower co-pays and raise fees for more effective treatmetns All of this will be based on patient profiles. Often, the treatment might be effective for 10% of patients for one reason or another, and in those cases, the won’t have to pay the higher co-pay and their doctor will get the higher fee.
    Barry–We’re not going to be trying to judge the quality of individual doctors– we know that the pool of patients is too small for it to work.
    Moreover, we know that these days, a patient’s outcome is virtually never the result of what one doctor did. Even in surgery, there is a team in the OR, and before the OR there are the people who prepped the patients, and after the operation their are the people who do rehab . . .And then there is the doctor who diagnosed and recommended surgery in the first place.
    We’re going to be rating the quality of all of the people who came in contact with the patient together and “bundling their payment” with a higher payment based on better outcomes.
    EVeryone–On LBJ– Such an interesting character. I’ve also read Caro and I
    see LBJ as a liberal on domestic issues, in some ways far more liberal than most of today’s liberal Democrats because he was willing to stick his neck out.
    He took a position on Civil Rights that he knew would cause the Democrats to lose the South. And LBJ did not like losing. But he insisted on voting rights.
    I lived in upstate NY at the time in a city where there was a lot of racism.
    The “centrist” voters there hated LBJ; northerners could be just as racist as any southerners. In particular, they hated the idea of their children going to school with black children.
    There was some centrist support–but also much centrist opposition to school integration.
    Finally, LBJ launched a war on poverty that worked. I’ve run the chart on Healthbeat before–you can see the percentage of poor decline during his time in office.
    Sometime in the 1980s, America lost interest in the poor.
    Reagan turned the country against the poor with his stories of welfare queens (totally made up) and by the time we got to the 1990s, upper middle class people thought it was hilarious to make fun of bag ladies. (Skits on TV–maybe even on Saturday Night Live?– and I saw this on the N.Y. subway, where young Wall Streeters in suits mocked bag ladies on the train.)
    Concern for the poor fell out of fashion, or was seen as a “bleeding heart” issue. Meanwhile New Democrats focosed on getting votes in the suburbs.
    It’s as if we’ve given up on the poor, just as we have given up on public schools in many of our cities, given up on those who are addicted to drugs, etc.
    I think Obama may change that. I like the investment in community clinics and public schools.
    Clearly, he wants to redistribute income, and
    I am hoping that the recession/depression will give him the political cover he needs to launch a new War on Poverty.

  23. We always have new tests coming into use, and data always lags current practice. Many things, like tight glucose control in diabetics, persists as a “best practice” despite a (unexpected and surprising) lack of supporting evidence in study data. In spite of the evidence, most doctors still support tight control.
    A similar thing occurred with cardiac surgery with CABG surgery becoming widespread for many years, in spite of a muddled performance in clinical trials, before hard data regarding effectiveness emerged.
    This is going to be a lot harder than most think it will be. Most medical procedures will be hard to justify. Almost all cardiology procedures will show marginal benefit. Most are marginal now actually…interestingly, the stress test which when positive for a young woman is almost always wrong, but they are still done. Almost all cancer treatment could be scraped, with little effect on overall mortality. Most all spine surgery and more than a few orthopedic procedures won’t pass muster.
    Overuse has become so ingrained, it will be very difficult to identify, let alone eradicate. The overuse problem is worst in the academic centers where the attendings have only a passing interest in clinical care. It will take a long time to change the culture.
    The reason that clinic style practices can skimp on actual medical treatment, HMO style, is that most of it has only marginal benefit. As you have pointed out earlier , if the patient has a fancy private room, and a TV, than good medical care. These clinics pedal a salaried staff that enthusiastically does as little as possible. The doctors are checking their watches starting at 3pm.
    Here your problem is getting something done, when you need it.
    In the final analysis, no one knows whether the greedy doctors are right to do something or the greedy HMO is right to NOT do something, in the individual case.
    My suspicion is that if you are actually sick, you are better off getting a real doctor, not a clinic doctor. The clinic doctor is so accustomed to worried well, he may not be the one to go to when you are actually sick.
    Our clinic doctors have operating times several times as long as regular doctors performing common operations like appendectomies.
    If you are not sick you are much better off with a clinic doctor, since if you are not sick, treatment is likely to do harm, if anything.
    Taken together, all medical care has little effect on life expectancy. So, it is really about re-dialing patient expectations.
    Patients don’t want to hear that now.
    Unfortunately for Maggie, most of the things that really do help..joint replacement, valve replacement, bowel surgery, cancer surgery, are done by those high paid skilled specialists she sees as the problem. There won’t be too many around soon. Believe it or not, you will miss them when they are gone.
    I think one of the many problems which evidence based decision trees is going to be the sparse data, and the numerous confounding variables.
    I think the intractable problems of smoking, obesity, sloth, drug and alcohol abuse will be like pulmonary embolis…they certainly kill people, But it is not that clear that expensive treatment makes a great impact on the problem.
    The great clinics, in Cleveland and Rochester, MN were built to support the advance of surgery. Surgery works for a lot of things. Sure, it is overused. But, in the right setting, it works.
    Can the same be said for a lot of the “feel good” measures which are going to be promoted as a substitute?
    This is going to be very difficult.

  24. You’re right–professional specialty societies are not the source of innovation in medical care. If I said “professional societies”, I should have said “practitioners who are up on the research in their specialty.” Professional societies, especially those of specialists, are the defenders of the status quo, of the high incomes and political clout that their members enjoy. There are organizations like the American College of Obstetricians and Gynecologists (ACOG), who claim that the “standard of care” is whatever they say it is (you can find it on their web site).
    I was referring to cases where “best practices” are known; for example, pediatricians know by now that self-management by their asthmatic patients results in far fewer hospital admissions, fewer missed school days, and more self-confidence in their patients vis a vis their disease. However, some pediatricians, both in solo practices and in large groups, still don’t take the time to teach their patients asthma self-management techniques, or don’t hire health educators to do this for their patients, resulting in higher rates of hospital readmissions, higher costs, poorer outcomes, etc.
    Guidelines are not “standards” (although they may become de facto standards). They are submitted by medical professionals as recommendations and then subjected to discussion and further systematic research. There are excellent sources for systematic research, such as the Cochrane Database (again, “not invented here,” but in the UK. Why do Americans always have to reinvent the wheel “in a uniquely American way”, while adding costs to the system and experimenting on their patients?) Further implementation of the guidelines with measurements of outcomes and impacts is what leads to real knowledge and innovation, and better health outcomes. This is true whether or not the professional societies are on board.

  25. I did not see one comment or read one sentence in Jim Jaffe’s post regarding lawsuits against providers for malpractice. One of the drivers of over testing is the need to deflect liability from any action/procedure/care on the part of the provider. Further, the overhead cost created by the medical malpractice insurance premiums is increasingly formidable. As the courts continue to be flooded with suits, the costs of med mal insurance will continue to escalate. The over testing will continue unabated as providers naturally try to cover themselves. The spiral of costs due to lawsuits will continue without adequate tort reform. Who among the health care reformers is willing to acknowledge and tackle this glaring issue?

  26. ACarrol, Christopher, Scott . .
    ACarrol–
    Thanks you draw a very helpful distinction between “guidelines” approvaed by professional societes, and guidelines created by those who keep up with the evidenc. .
    Also, you write: “There are excellent sources for systematic research, such as the Cochrane Database (again, “not invented here,” but in the UK. Why do Americans always have to reinvent the wheel “in a uniquely American way”, while adding costs to the system and experimenting on their patients?)”
    Absolutely true.
    Scott–
    I’ve written about malpractice and defensive medicine numerous times on this blog.
    It’s a problem especailly in certain specialties, but hard to untangle from the perverse incentives that “fee-for-service” creates.
    In other words, doctors often have two or three or four reasons for doing what they do, with fear of malpractice one of them.
    Dartmouth has some interesting numbers about all of this, and I’ll be writing about them soon.
    Christopher
    Much of what you say is true about overtreatment in cardiac care, cancer care, orthopedics etc.
    But I really don’t know what you mean by “clinic doctors”
    The docs at Geisinger or INterMountain or Kaiser?
    They all practice “evidence-based” medicine, and they are so skilled that they are able to get better outcomes while charging Medicare 50% less than UCLA hospital or NYC”s major hospitals.
    (You really owe it to yourself to read the Dartmouth Research–www.dartmouthatlas.org and look at their comparisons of hospitals)
    As for the “high-paid specialists” doing the life-saving work–
    I agree that specialists at Mayo and Cleveland Clinic do good evidence-based work, but they are not the “high-paid” specialists you find at the brand-name hopsitals Northeast or in Florida or Southern California.
    As you know docs at Mayo and Cleveland Clinic are on salary, and at Mayo, after the first five years, all of the docs in a specialty earn the same salary–it doesn’t matter if you’re an int’l super-star or a rain-maker.
    Many docs at Cleveland Clinic could make more in a fee-for-service system.
    So “high-paid specialists” does not equal “highest quality.”
    To the contrary, research shows that docs who work on salary, or in a capitated system in large multi-specialty centers tend to get the best outcomes at the lowest price. (i.e value for our healthcare dollars.)
    On overtreatment by “highly paid specialists”
    I urge you to read “A Very Open Letter From an Oncologist” http://www.healthbeatblog.org/2009/01/a-very-open-letter-from-an-oncologist.html.
    Much cancer sugery is futile– or unneeded. The 35-year-old who has a lumpectomy after a doctor does a MRI and finds a tiny lesion that would have disappeared.
    AT NYU hospital, Tom Riles, head of cardiac has told me that those “really good specialists” continue to do far too many bypasses .
    At all of those top tier hopsitals in Boston, New York, L.A. etc where you have supposedly “really good specialists,” they are doing way too many joint and knee replacements.
    Shared Decision-Making reserach done at Dartmouth and Ottawa shows that if patients are given full information about recovery time, side effects, etc. 20% to 30% decide not to have the surgery.
    For some, medication and physical therapy are sufficient. Much depends on how active they are.
    If you are 70 years old, spend most of your time reading and don’t play tennis, it really may not be worth it.
    Finally on smoking, drinking drugs . . .I agree that access to medical care is not the key. Lifting people out of poverty is what is needed.
    As I have written poverty leads to anxiety and depression, and then people self-medicate . ..

  27. Scott, I’m in too good a mood to bicker this evening, but I would like to say, it was our experience that the medical profession had become highly skilled in avoiding and evading any responsibility or accountability ie: a lawsuit, but they took no action toward avoiding the negligence that triggers lawsuits in the first place. Not that I ever threatened a lawsuit, but here’s an example of a common exchange: Me to nurse “What happened to the back of his head?” (pointing to a bulge the size of a baseball) Nurse to me: “Nothing, that’s his normal head.” Me to nurse “No, it isn’t, he’s bald, I know what the back of his head looks like and it doesn’t have a baseball on it.” (thinking to myself, I need to start turning his head regularly because I think that’s what’s called a ‘bedsore.’) Nurse to me: “No, it’s his normal head, see, feel the back of my head, I have a knot. Besides, the only way we would ever know is if we had a photograph of the back of his head when he was admitted, and we don’t have that so there’s no way to prove that’s not his normal head. Here, feel the back of my head…”
    Scott, here’s a link you might appreciate: http://www.americastunnelvision.com/home.php

  28. Anon,
    Grab a latte, a tea or a gin and tonic depending on the time of the day….. this is long.
    I have been reading the stream of emails between you and Lisa bout bilirubin testing and I find your comments fascinating, puzzling and, quite honestly, somewhat chilling. I am Susan Sheridan (the horses mouth)a mom of a boy with kernicterus and one of the co-founders of PICK (Parents of Infants and Children with Kernicterus.) Our organization is 10 years old and has successfully partnered with dedicated experts in bilirubin management and every agency, organization and non profit that has anything to do with the safety of newborns. Our web site will give you many of the links that you want and also follow the link to the CDC and watch the PICK “Prevent this” video (under free downloads) that has JC, CDC, NIH, experts, March of Domes, mothers, and children.
    Lisa has pulled NOTHING out of the air and she corrected herself regarding the AMA.
    The Joint Commission issued two sentinel event alerts warning about the dangers of visual assessment and highlighting the importance of objective testing in all newborns. The CDC has also issued a series of public health alerts calling for bilirubin testing. NQF has identified kernicterus and bili levels over 30 as a “Never Event” in their list of 27 adverse outcomes that should never happen in the USA and has proposed universal bilirubin testing as a quality indicator. AWHONN and NANN published position statements in favor of universal bilirubin testing, HCA and Intermountain Healthcare have instituted universal predischarge bili testing and have published results showing a reduction in kernicterus and bilis over 30 as well as a 30% reduction in newborn readmission. There is plenty of evidence to show the benefits of universal bilirubin testing as a way to predict and treat hyperbilirubinemia. All of the above happened despite the reluctance and pushback from the AAP – although their 2004 guidelines indicate that the best documented method for predicting hyperbilirubinemia is through universal testing. They have been wanting more evidence and I believe they now feel that the evidence supports universal bili testing. I would anticipate an announcement very soon.
    Regarding the cost benefit that you mention. I believe that you are referring to an article that came out in Pediatrics a few years ago that was hotly contested and even the authors admitted to limitations of their study. Their conclusions were based on 2 major unknowns. – Prevalence and cost of kernicterus. Regarding prevalence, 10 years ago it was believed that kernicterus didn’t even exist in the USA. Thanks to PICK, CDC, researchers such as Vinny Bhutani , Audry Brown and Lois Johnson, we now know that the prevalence is far greater than ever expected. It is a classic case of a problem flying under the radar with no surveillance. HCA found in a retrospective analysis that they had 13 “Never events”/cases of kernicterus in only an 8 month period of time. They deliver 225,000 and about 4 million newborns are born every year. You can see that this is not an insignificant number of newborns .
    Regarding cost, the authors of the article simply took the dollar figure of $900,000 off the CDC’s economic burden of disability list for Cerebral Palsy. Many of our kids with kernicterus have multiple surgeries, feeding tubes, have to be suctioned, a lifetime of nursing care, OT,PT and speech therapy, have intrathecal baclofen pumps, spines fused, tracheas, and botox injections. Many need technology to speak and cochlear implants to hear. Some are in chronic pain because of spasticity and some end up in nursing homes because we simply can’t’ take care of them. Our kids can easily consume $900,000 in less than 1 year and their lifecare plans are in the multimillion dollar range. And how in the world do we put a price tag on a newborn? By the way, a bili test costs about one dollar according to information on the AAP website. Of course there are additional costs on top of that, but, never the less ,it is inexpensive.
    Your comparison of testing all newborns’ bilirubin to a bone marrow biopsy in young children is curious and unfortunate. By law, all newborns have to get a heel stick for PKU and other metabolic abnormalities. Many hospitals do the bili at the same time as the PKU at an incremental cost and no additional pain to the baby. To my knowledge there is no similar requirement by law for youngsters to undergo a biopsy type procedure.
    So , Anon305, I hope that you can appreciate the information that I have shared. I guess I shouldn’t expect all healthcare professionals to follow the advancements of jaundice management, but I have learned from the trenches. I have been involved every step of the way of the evolution of how jaundice is managed and I must say getting safer and I ….and we …will never stop until all newborns are safe and moms and dads don’t experience what we have. I don’t think this is asking too much of our healthcare system. Besides, 60% of all newborns get jaundice after birth. The main symptom of jaundice is a the yellowing of the skin color. Considering our eyes fail us because we are human combined with the reality that the USA has quite an ethnic mix and a variety of skin colors in our population if we don’t’ test all newborns then the healthcare system is simply rolling the dice and crossing their fingers.
    I agree that there is overtreatment in areas of the healthcare that needs to be controlled, but one must be very smart when cutting back. in the early 1990s an article came out “The kinder Gentler Approach….” warning of the over testing and overtreating of jaundice. What resulted was an unfortunate reemergence of kernicterus and a population of kids just like my son.
    Obviously I know a lot about kernicterus. I honestly wish I knew nothing of it. Thanks for reading this. And Lisa, thanks for bringing this up. Sue
    Anon305,
    Grab a latte, a tea or a gin and tonic depending on the time of the day….. this is long.
    I have been reading the stream of emails between you and Lisa bout bilirubin testing and I find your comments fascinating, puzzling and, quite honestly, somewhat chilling. I am Susan Sheridan (the horses mouth)a mom of a boy with kernicterus and one of the co-founders of PICK (Parents of Infants and Children with Kernicterus.) Our organization is 10 years old and has successfully partnered with dedicated experts in bilirubin management and every agency, organization and non profit that has anything to do with the safety of newborns. Our web site will give you many of the links that you want and also follow the link to the CDC and watch the PICK “Prevent this” video (under free downloads) that has JC, CDC, NIH, experts, March of Domes, mothers, and children.
    Lisa has pulled NOTHING out of the air and she corrected herself regarding the AMA.
    The Joint Commission issued two sentinel event alerts warning about the dangers of visual assessment and highlighting the importance of objective testing in all newborns. The CDC has also issued a series of public health alerts calling for bilirubin testing. NQF has identified kernicterus and bili levels over 30 as a “Never Event” in their list of 27 adverse outcomes that should never happen in the USA and has proposed universal bilirubin testing as a quality indicator. AWHONN and NANN published position statements in favor of universal bilirubin testing, HCA and Intermountain Healthcare have instituted universal predischarge bili testing and have published results showing a reduction in kernicterus and bilis over 30 as well as a 30% reduction in newborn readmission. There is plenty of evidence to show the benefits of universal bilirubin testing as a way to predict and treat hyperbilirubinemia. All of the above happened despite the reluctance and pushback from the AAP – although their 2004 guidelines indicate that the best documented method for predicting hyperbilirubinemia is through universal testing. They have been wanting more evidence and I believe they now feel that the evidence supports universal bili testing. I would anticipate an announcement very soon.
    Regarding the cost benefit that you mention. I believe that you are referring to an article that came out in Pediatrics a few years ago that was hotly contested and even the authors admitted to limitations of their study. Their conclusions were based on 2 major unknowns. – Prevalence and cost of kernicterus. Regarding prevalence, 10 years ago it was believed that kernicterus didn’t even exist in the USA. Thanks to PICK, CDC, researchers such as Vinny Bhutani , Audry Brown and Lois Johnson, we now know that the prevalence is far greater than ever expected. It is a classic case of a problem flying under the radar with no surveillance. HCA found in a retrospective analysis that they had 13 “Never events”/cases of kernicterus in only an 8 month period of time. They deliver 225,000 and about 4 million newborns are born every year. You can see that this is not an insignificant number of newborns .
    Regarding cost, the authors of the article simply took the dollar figure of $900,000 off the CDC’s economic burden of disability list for Cerebral Palsy. Many of our kids with kernicterus have multiple surgeries, feeding tubes, have to be suctioned, a lifetime of nursing care, OT,PT and speech therapy, have intrathecal baclofen pumps, spines fused, tracheas, and botox injections. Many need technology to speak and cochlear implants to hear. Some are in chronic pain because of spasticity and some end up in nursing homes because we simply can’t’ take care of them. Our kids can easily consume $900,000 in less than 1 year and their lifecare plans are in the multimillion dollar range. And how in the world do we put a price tag on a newborn? By the way, a bili test costs about one dollar according to information on the AAP website. Of course there are additional costs on top of that, but, never the less ,it is inexpensive.
    Your comparison of testing all newborns’ bilirubin to a bone marrow biopsy in young children is curious and unfortunate. By law, all newborns have to get a heel stick for PKU and other metabolic abnormalities. Many hospitals do the bili at the same time as the PKU at an incremental cost and no additional pain to the baby. To my knowledge there is no similar requirement by law for youngsters to undergo a biopsy type procedure.
    So , Anon305, I hope that you can appreciate the information that I have shared. I guess I shouldn’t expect all healthcare professionals to follow the advancements of jaundice management, but I have learned from the trenches. I have been involved every step of the way of the evolution of how jaundice is managed and I must say getting safer and I ….and we …will never stop until all newborns are safe and moms and dads don’t experience what we have. I don’t think this is asking too much of our healthcare system. Besides, 60% of all newborns get jaundice after birth. The main symptom of jaundice is a the yellowing of the skin color. Considering our eyes fail us because we are human combined with the reality that the USA has quite an ethnic mix and a variety of skin colors in our population if we don’t’ test all newborns then the healthcare system is simply rolling the dice and crossing their fingers.
    I agree that there is overtreatment in areas of the healthcare that needs to be controlled, but one must be very smart when cutting back. in the early 1990s an article came out “The kinder Gentler Approach….” warning of the over testing and overtreating of jaundice. What resulted was an unfortunate reemergence of kernicterus and a population of kids just like my son.
    Obviously I know a lot about kernicterus. I honestly wish I knew nothing of it. Thanks for reading this. And Lisa, thanks for bringing this up. Sue
    Anon305,
    Grab a latte, a tea or a gin and tonic depending on the time of the day….. this is long.
    I have been reading the stream of emails between you and Lisa bout bilirubin testing and I find your comments fascinating, puzzling and, quite honestly, somewhat chilling. I am Susan Sheridan (the horses mouth)a mom of a boy with kernicterus and one of the co-founders of PICK (Parents of Infants and Children with Kernicterus.) Our organization is 10 years old and has successfully partnered with dedicated experts in bilirubin management and every agency, organization and non profit that has anything to do with the safety of newborns. Our web site will give you many of the links that you want and also follow the link to the CDC and watch the PICK “Prevent this” video (under free downloads) that has JC, CDC, NIH, experts, March of Domes, mothers, and children.
    Lisa has pulled NOTHING out of the air and she corrected herself regarding the AMA.
    The Joint Commission issued two sentinel event alerts warning about the dangers of visual assessment and highlighting the importance of objective testing in all newborns. The CDC has also issued a series of public health alerts calling for bilirubin testing. NQF has identified kernicterus and bili levels over 30 as a “Never Event” in their list of 27 adverse outcomes that should never happen in the USA and has proposed universal bilirubin testing as a quality indicator. AWHONN and NANN published position statements in favor of universal bilirubin testing, HCA and Intermountain Healthcare have instituted universal predischarge bili testing and have published results showing a reduction in kernicterus and bilis over 30 as well as a 30% reduction in newborn readmission. There is plenty of evidence to show the benefits of universal bilirubin testing as a way to predict and treat hyperbilirubinemia. All of the above happened despite the reluctance and pushback from the AAP – although their 2004 guidelines indicate that the best documented method for predicting hyperbilirubinemia is through universal testing. They have been wanting more evidence and I believe they now feel that the evidence supports universal bili testing. I would anticipate an announcement very soon.
    Regarding the cost benefit that you mention. I believe that you are referring to an article that came out in Pediatrics a few years ago that was hotly contested and even the authors admitted to limitations of their study. Their conclusions were based on 2 major unknowns. – Prevalence and cost of kernicterus. Regarding prevalence, 10 years ago it was believed that kernicterus didn’t even exist in the USA. Thanks to PICK, CDC, researchers such as Vinny Bhutani , Audry Brown and Lois Johnson, we now know that the prevalence is far greater than ever expected. It is a classic case of a problem flying under the radar with no surveillance. HCA found in a retrospective analysis that they had 13 “Never events”/cases of kernicterus in only an 8 month period of time. They deliver 225,000 and about 4 million newborns are born every year. You can see that this is not an insignificant number of newborns .
    Regarding cost, the authors of the article simply took the dollar figure of $900,000 off the CDC’s economic burden of disability list for Cerebral Palsy. Many of our kids with kernicterus have multiple surgeries, feeding tubes, have to be suctioned, a lifetime of nursing care, OT,PT and speech therapy, have intrathecal baclofen pumps, spines fused, tracheas, and botox injections. Many need technology to speak and cochlear implants to hear. Some are in chronic pain because of spasticity and some end up in nursing homes because we simply can’t’ take care of them. Our kids can easily consume $900,000 in less than 1 year and their lifecare plans are in the multimillion dollar range. And how in the world do we put a price tag on a newborn? By the way, a bili test costs about one dollar according to information on the AAP website. Of course there are additional costs on top of that, but, never the less ,it is inexpensive.
    Your comparison of testing all newborns’ bilirubin to a bone marrow biopsy in young children is curious and unfortunate. By law, all newborns have to get a heel stick for PKU and other metabolic abnormalities. Many hospitals do the bili at the same time as the PKU at an incremental cost and no additional pain to the baby. To my knowledge there is no similar requirement by law for youngsters to undergo a biopsy type procedure.
    So , Anon305, I hope that you can appreciate the information that I have shared. I guess I shouldn’t expect all healthcare professionals to follow the advancements of jaundice management, but I have learned from the trenches. I have been involved every step of the way of the evolution of how jaundice is managed and I must say getting safer and I ….and we …will never stop until all newborns are safe and moms and dads don’t experience what we have. I don’t think this is asking too much of our healthcare system. Besides, 60% of all newborns get jaundice after birth. The main symptom of jaundice is a the yellowing of the skin color. Considering our eyes fail us because we are human combined with the reality that the USA has quite an ethnic mix and a variety of skin colors in our population if we don’t’ test all newborns then the healthcare system is simply rolling the dice and crossing their fingers.
    I agree that there is overtreatment in areas of the healthcare that needs to be controlled, but one must be very smart when cutting back. in the early 1990s an article came out “The kinder Gentler Approach….” warning of the over testing and overtreating of jaundice. What resulted was an unfortunate reemergence of kernicterus and a population of kids just like my son.
    Obviously I know a lot about kernicterus. I honestly wish I knew nothing of it. Thanks for reading this. And Lisa, thanks for bringing this up. Sue
    Anon305,
    Grab a latte, a tea or a gin and tonic depending on the time of the day….. this is long.
    I have been reading the stream of emails between you and Lisa bout bilirubin testing and I find your comments fascinating, puzzling and, quite honestly, somewhat chilling. I am Susan Sheridan (the horses mouth)a mom of a boy with kernicterus and one of the co-founders of PICK (Parents of Infants and Children with Kernicterus.) Our organization is 10 years old and has successfully partnered with dedicated experts in bilirubin management and every agency, organization and non profit that has anything to do with the safety of newborns. Our web site will give you many of the links that you want and also follow the link to the CDC and watch the PICK “Prevent this” video (under free downloads) that has JC, CDC, NIH, experts, March of Domes, mothers, and children.
    Lisa has pulled NOTHING out of the air and she corrected herself regarding the AMA.
    The Joint Commission issued two sentinel event alerts warning about the dangers of visual assessment and highlighting the importance of objective testing in all newborns. The CDC has also issued a series of public health alerts calling for bilirubin testing. NQF has identified kernicterus and bili levels over 30 as a “Never Event” in their list of 27 adverse outcomes that should never happen in the USA and has proposed universal bilirubin testing as a quality indicator. AWHONN and NANN published position statements in favor of universal bilirubin testing, HCA and Intermountain Healthcare have instituted universal predischarge bili testing and have published results showing a reduction in kernicterus and bilis over 30 as well as a 30% reduction in newborn readmission. There is plenty of evidence to show the benefits of universal bilirubin testing as a way to predict and treat hyperbilirubinemia. All of the above happened despite the reluctance and pushback from the AAP – although their 2004 guidelines indicate that the best documented method for predicting hyperbilirubinemia is through universal testing. They have been wanting more evidence and I believe they now feel that the evidence supports universal bili testing. I would anticipate an announcement very soon.
    Regarding the cost benefit that you mention. I believe that you are referring to an article that came out in Pediatrics a few years ago that was hotly contested and even the authors admitted to limitations of their study. Their conclusions were based on 2 major unknowns. – Prevalence and cost of kernicterus. Regarding prevalence, 10 years ago it was believed that kernicterus didn’t even exist in the USA. Thanks to PICK, CDC, researchers such as Vinny Bhutani , Audry Brown and Lois Johnson, we now know that the prevalence is far greater than ever expected. It is a classic case of a problem flying under the radar with no surveillance. HCA found in a retrospective analysis that they had 13 “Never events”/cases of kernicterus in only an 8 month period of time. They deliver 225,000 and about 4 million newborns are born every year. You can see that this is not an insignificant number of newborns .
    Regarding cost, the authors of the article simply took the dollar figure of $900,000 off the CDC’s economic burden of disability list for Cerebral Palsy. Many of our kids with kernicterus have multiple surgeries, feeding tubes, have to be suctioned, a lifetime of nursing care, OT,PT and speech therapy, have intrathecal baclofen pumps, spines fused, tracheas, and botox injections. Many need technology to speak and cochlear implants to hear. Some are in chronic pain because of spasticity and some end up in nursing homes because we simply can’t’ take care of them. Our kids can easily consume $900,000 in less than 1 year and their lifecare plans are in the multimillion dollar range. And how in the world do we put a price tag on a newborn? By the way, a bili test costs about one dollar according to information on the AAP website. Of course there are additional costs on top of that, but, never the less ,it is inexpensive.
    Your comparison of testing all newborns’ bilirubin to a bone marrow biopsy in young children is curious and unfortunate. By law, all newborns have to get a heel stick for PKU and other metabolic abnormalities. Many hospitals do the bili at the same time as the PKU at an incremental cost and no additional pain to the baby. To my knowledge there is no similar requirement by law for youngsters to undergo a biopsy type procedure.
    So , Anon305, I hope that you can appreciate the information that I have shared. I guess I shouldn’t expect all healthcare professionals to follow the advancements of jaundice management, but I have learned from the trenches. I have been involved every step of the way of the evolution of how jaundice is managed and I must say getting safer and I ….and we …will never stop until all newborns are safe and moms and dads don’t experience what we have. I don’t think this is asking too much of our healthcare system. Besides, 60% of all newborns get jaundice after birth. The main symptom of jaundice is a the yellowing of the skin color. Considering our eyes fail us because we are human combined with the reality that the USA has quite an ethnic mix and a variety of skin colors in our population if we don’t’ test all newborns then the healthcare system is simply rolling the dice and crossing their fingers.
    I agree that there is overtreatment in areas of the healthcare that needs to be controlled, but one must be very smart when cutting back. in the early 1990s an article came out “The kinder Gentler Approach….” warning of the over testing and overtreating of jaundice. What resulted was an unfortunate reemergence of kernicterus and a population of kids just like my son.
    Obviously I know a lot about kernicterus. I honestly wish I knew nothing of it. Thanks for reading this. And Lisa, thanks for bringing this up. Sue