Nortin Hadler on How to Win the Healthcare Lottery Without Buying a Ticket

Below an excerpt from an essay by Dr. Nortin Hadlerprofessor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," "The Last Well Person," and “Stabbed in the Back.”

I am always delighted when Hadler contributes to HealthBeat. He is willing to tell the truth about medical evidence and comparative effectiveness research– even when candor may not be popular. You don’t have to agree with him, but without question, you should read his work.   Hadler is not a pundit offering one man’s opinion:  his writing is studded with footnotes and links to rigorous medical research.

This post is excerpted from a piece which originally appeared on ABC.com, Health Care Reform: The Difference Between Rationing and Rational.“There  Hadler explains why, if a doctor recommends angioplasty, you should ask some questions. At the end of the post, you will find my “Note” on what I find the most intriguing aspect of Hadler’s essay: how to win the healthcare lottery without buying a ticket.



In the United States, well over a million people undergo invasive coronary procedures each year for various manifestations of coronary artery disease including Coronary Artery Bypass Grafts, Angioplasties and surgeries involving Stents.                       

These are technological advances designed to overcome blocked arteries. They all have technical limitations in that the unblocking or bypassing tends to reverse itself. So there is much invested in the attempt to more permanently overcome the blockage.

There are four stents licensed for this purpose and many in the "pipeline"—and there are many surgical approaches to bypassing. There are also thousands of trials comparing one technique with another to determine the relative fate of the unblocking.

However, I don't care about the fate of the unblocking. I care about the fate of the patient. Is the patient better off for all this technology?

That central question gets lost in the race for technological achievement. There have been strong reasons for doubt for years. Doubt is now dispelled thanks to four recent randomized controlled trials comparing such interventions with medical care without the interventions.

Three of the trials were American—OAT, COURAGE and BARI 2D—and one—RITA-2—was European (these are all acronyms based on the type of heart disease studied). Each recruited thousands of patients and followed them for years. Each recruited a somewhat distinctive population in terms of the manifestations of their coronary artery disease (active angina, after a heart attack, angina and diabetes, etc.), but all recruited patients for whom interventional cardiology was thought to be a reasonable option.

 

No one, I'll say it again, NO ONE was advantaged by submitting to the intervention. They did not live longer, or have less chest pain, or suffer fewer heart attacks than they would have without the procedure.

When Clinical Science and Clinical Judgment are Dissonant

Not long ago, I attended "Grand Rounds" at a prominent medical school where the professor and director of the Cardiac Catheterization Laboratory was holding forth on the mechanisms by which newer stents can stay open longer. I asked him how he explains the stent option to a patient with chest pain in view of the results of OAT, COURAGE, BARI 2D and RITA-2. He, of course, was aware of all these trials. Even though the trials recruited patients with four very typical patterns of disease, he suggested many patients do not quite fit these categories. He was willing to rely on his clinical judgment to infer that a particular patient would be advantaged because he is endowed with a special level of expertise.

I asked him if he told the patient that his judgment was superseding a compelling science and that his judgment had not been subjected to testing. He ducked the question. As far as I'm concerned, when the precedent is not even encouraging, such an inference demands scientific validation before it is put into clinical practice.

The Lottery Mentality

For me, this is irrational behavior on the part of the patient and worse on the part of the navigator [the physician]. It survives in America because of what I call the "lottery" mentality: "Doc, if you can get me through this and it only works one time in a thousand, I want to be that one. Go for it!" True, someone wins the lottery, even if it's exceedingly improbable. But the science we're considering is not a lottery. The argument that pertains is that the patient is as likely to do as well without the procedure as with it. It would be as if you could win the lottery without buying a ticket.

Furthermore, would the American lottery mentality drive clinical decision making if the patient had to buy the "ticket" instead of all of us sharing its cost?  And if we knew the science, would we be willing to share the cost?  If not, is that rationing, or rational?

Rational Reform

"No discernible benefit," we can free up about half of the finite resource and easily provide rational care and caring for all.

Then we can tackle the thorny issues of interventions that work sometimes or just a little, and of interventions yet to be discovered. If we hold the care of the patient as the entire reason for the enterprise, even the thorniest of issues are surmountable.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Note from mm: I particularly like Hadler’s “lottery” argument.” He suggests that the patient who doesn’t buy a ticket for a lottery which offers him a one in 1,000 chance of winning might actually walk off with the prize.

When I first read the post, it took me a minute or two to understand what Hadler was saying. While Hadler is  undeniably right, his argument is counter-intuitive.  On the face of it, the patient who says, “Doc, if . . .  this works one time in a thousand, I want to be that one. Go for it!" sounds sensible, especially if his insurer covers the treatment.  If the patient doesn’t have to pay for it, why not take the shot?

Because every medical treatment and test carries some risks.  Imagine a 60-year-old male who decides not to undergo a PSA test for prostate cancer. He lives for another 25 years and never experiences any symptoms of this slow-growing cancer—even though, if he had been tested and a biopsied when he was 60,  he would have been diagnosed with early stage prostate cancer.  Twenty years later he dies of something else, without every knowing that he has cancer.  Like the majority of American men of his age, he dies “with” prostate cancer, but not “of” it. 

 

He has won the lottery while not buying a ticket: He didn’t “buy” the PSA test, and as a result, he never experienced the anxiety of knowing that he had cancer, and he never suffered the side effects associated with treatment for early-stage prostate cancer (which can include incontinence and impotence).  

Of course, his undetected prostate cancer might have spread silently and killed him.  But the National Cancer Institute (NCI) tells us that “the benefits of screening and local therapy (surgery or radiation therapy) for early-stage prostate cancer remain unclear.”

We don’t have evidence that screening and early detection saves any lives. In fact, initial results from a long-term trial supported by the NCI show that “annual PSA testing for 6 years  . . .  did not reduce the number of prostate cancer deaths through a median follow-up period of 11.5 years.”

Or, as Hadler puts it, this is a case where “the patient is as likely to do as well without the treatment.”  Thus, it makes little sense to buy the ticket, and expose yourself to the risks of unproven tests and procedures.

14 thoughts on “Nortin Hadler on How to Win the Healthcare Lottery Without Buying a Ticket

  1. See — “RATIONAL” 🙂
    Refusing to pay for ineffective care, whether it is rhinoceros horn powder or coronary stent placement, is not rationing.
    In the face of a major crisis that will destroy both health care and in the economy, it is rational.

  2. What I find most disturbing is the response of the cardiologist who is willing to discard the results of four large high quality studies and substitute his own anecdotal evidence base because he thinks he is smarter and special and all of his patients are special.
    I find this type of thinking as maddening as it is pervasive in the medical community. It is the greatest single obstacle to the practice of high quality and cost effective medicine that we face.
    The obvious financial conflicts of interest only serve to highlight the hypocrisy. (It is rare that a doctor will decide to override studies when they justify increasing his income.)
    It seems that every day I read where some random doctor is posting that he knows better because he is smarter and his patients are special compared to rigorous peer reviewed studies. This is a financial and cultural barrier that must be overcome.

  3. The question is why do insurance companies, including Medicare, continue to reimburse for this if it offers no benefit? And why doesn’t the American College of Cardiology offer strong guidelines for this if this is the case?
    Probably too many vested interests from the hospitals to the providers to the manufacturers of the stents that would bring their lobbying power to bear if any such change was entertained. And of course, who is the patient going to believe; the big, bad insurance company not paying for his stent or the cardiologist who tells him he needs to have one?
    One could imagine that if insurers didn’t pay for stenting, a situation where cardiologists have a patient on the table and tell him he/she needs a stent in their opinion, but his insurer will not pay for it, and it will cost him 20 grand to have it put in.
    What is a patient to do in this circumstance?

  4. Thanks Maggie-
    Nortin Hadler was always and remains WAY ahead of the pack. I doubt if he or I(or you) will live to see the fruits of his genius and courage.
    But the seeds are planted for future generations who will benefit from his body of work.
    Dr. Rick Lippin
    Southampton,Pa
    “CHARTER HADLERIAN”

  5. Mark
    Mark– Yes, I’m afraid that sheer arrogance is costing us billions–while
    putting patients at risk.
    Keith–
    It’s not just the stent manufacturer, the hospitals and many cardiologists who would protest if Medicare stopped paying for most angioplasties– patients would be outraged.
    Unfortunately, the average American has little respect for science or experts. And most would prefer to believe that there is a quick fix for whatever ails them.
    We saw this in the 1990s, when insurers did try to manage care–and costs. Sometimes they refused to pay for effective treatments, but very often they were refusing to pay for ineffective treatments.
    Nevertheless, both the public and the media blamed the insurance companies–rather than
    listening to those honest health professionals who tried to explain that bone marrow transplants were not going to help women with breast cancer.
    So the insurers were crucified and ultimately gave up.
    This is also why so many people prefer to believe that insurers are responsible for most of what is wrong with our health care system–and if we only had single payer everything would be fine.
    Insurers began to be perceived as the villians in the 1990s when they were in fact sometimes doing the right thing.
    One rarely hears single-payer advocates talk about over-treatment. Too often, they seem to suggest that if we just got rid of the insurers, we could all have whatever care we want (or our doctors recommend) without worrying about medical evidence, and it would all be affordable.
    Pat–Yes overtreatment is a major threat to the economy.
    Rick-I agree Thank you.

  6. It seems as though American medicine has this country in a trance of denial. They can only do good with no wrong. The idea of accountability for results over doing nothing seems to be foreign to the system, and how did that ever evolve??
    When that IOM report in 1999 came out showing medical errors to be one of the largest causes of death in America, it just amazed me that that document got so little traction and press. If you add the morbidity and mortality of marginal treatments to the morbidity and mortality of medical error, well it is truly amazing that anyone voluntarily submits to the system at all. Can you think of any other social interaction that would tolerate such dangers without upfront clear proof of benefits in many areas??

  7. one doesn’t have to be a credit card company to realize there’s a lot of money to be made by catering to whims that seem irrational to some. optional guarantees on appliances come to mind as does any kind of insurance with first dollar coverage. people rate risks differently. some would prefer to risk their lives on a procedure that could save them rather than doing so with watchful waiting. in the former case, they feel like they’re managing the issue rather than being managed by it. don’t know how helpful it is to categorize such behavior as irrational.

  8. “Refusing to pay for ineffective care, whether it is rhinoceros horn powder or coronary stent placement, is not rationing.”
    Pat, can I steal that to engrave on a plaque to hang on my wall?

  9. Thanks for this, Maggie.
    How do we sign up to be Hadlerians, too?
    Cardiac stents are very, very big business, with powerful stent manufacturers like Johnson & Johnson and Boston Scientific selling over $3 billion worth of stents last year. They have invested heavily in expanding the use of these stents; stent implants have become more popular as rates for the more invasive open heart bypass surgery have dropped. According to the New York Times:
    “The specialists who are most likely to diagnose coronary artery disease are in many cases also the doctors who implant stents. Cardiac surgeons have seen their annual incomes dwindle to an average $425,000 down from $1.02 million in 1990, after adjusting for inflation. Meanwhile, the average income of an interventional cardiologist has risen to $550,000 from an inflation-adjusted $392,000.”
    So if you’re a stent-happy interventional cardiologist holding a hammer, every coronary artery blockage looks like a nail…
    Cheers,
    Carolyn

  10. Carolyn,Chris, Jim, NG
    Carolyn–
    One way to sign on as a Haderian is to buy his book, “Worried Sick” (probably very clean copies are available at a low price on http://www.Amazon.com.
    Another book, “The Last Well Person” is also outstanding.
    And yes, stenting has become a huge business for the companies that manufacture stents.
    Many of the doctors (internventionists) who use them are completely honest and believe in the technology.
    And for elderly patietns, who may well die on the operating table if they have bypass surgery (which involved cracking the chest open) less invasive operations using stents may help them without killing them.
    But without question, the manufactuers have hyped the product, making a fortune on it. And some doctors receive enormous fees from manufactuers to spread the word . .
    Chris–
    Good to hear from you. Would love to see that plaque in many doctors’ offices
    Jim–
    We’re not talking about “whims that seem irrational to some” or “optional insurance on appliances.”
    We’re talking about spending bilions on treatments and tests that provide no benefits– and put patients at risk.
    And we’re talking about hard numbers proivded by medical evidence.
    Unfortunately, many Americans are suspicious of science and this has led to great harm (punishing teachers who taught Darwin’s theories, spreading candards about Gays, Jews (that they have horns), African-Americans (they they, unlike white Americans,are descended from Apes) and of course, the recent notion that palliative care and hospice care are tied up with “death panels”–ignoring the evidence that patients who receive hospice care actually Live Longer.
    Facts are facts. Those who ignore them–especially when we are talking about life and death issues– are irrational.
    NG–
    You write: “Can you think of any other social interaction that would tolerate such dangers without upfront clear proof of benefits in many areas?”
    No, I can’t.
    But most Americans find the idea that medical errors are commonplace in our hospitals just too scarey to contemplate. They don’t want to know that. They don’t want to hear it.
    Moreover the American Medical Assocation has spent decades putting doctors on a pedestal–doing a great disservice to physicians as well as patients.,
    Often, doctors are hesitant about saying “I don’t know” beuause patients have been taught that a good doctor is all knowing.
    Most patients don’t want to hear that medicine is shot through with ambiguity and uncertainty and that, in many cases, “We just don’t know” is the most honest answer that a physician could give them.
    So patients close their eyes, and don’t ask questions.

  11. As a retired specialist in a field unrelated to heart care, I read this post and the original Hadler article, and was left with the impression that Hadler was painting bypass surgery with the same unflattering brush as stents. The four studies told a different story, and thanks also, Carolyn, for your comment separating the two. Based on my cursory evaluation of evidence, I had already instructed my wife that if I was ever given a choice between stent and bypass, and I was not in a condition to decide, to please opt for a bypass for me (assuming the choice “neither” was not a scientifically supported option).
    Then a year ago, I followed at a distance the nightmare post-op saga of a old college friend, who had been treated with a coronary artery stent in an apparently urgent situation. Complications led to multiple abdominal operations, cardiac arrests, repeated CPR, liver and kidney failure, prolonged disability, and undoubtedly an extremely high payout from his health insurance company. In the middle of all that horrendous suffering, it would never be helpful for me to ask the rational for the treatment already done. Thanks to miraculous medical care following this iatrogenic trauma (and perhaps because he was in superb condition pre-op except for that coronary artery), he is now back to part-time involvement in his profession. This undocumented anecdote is not intended to disprove the value of interventional cardiology, but neither do “good results” unsupported by controlled studies justify risky or expensive interventions.
    Another tidbit: Bill Gates cited a statistic in a recent interview (he has legitimate medical economics expertise given the recent concentration of his considerable brain power and wealth on world health issues) indicating that the first 2% of health expenditures account for 50% of a developing nation’s health benefit. So it should not be surprising that we get so little from the extra 5% or more of GDP that we spend vs. other developed nations.
    Thanks again for your great blog.

  12. It would be telling to know which screenings, procedures and surgeries medical doctors actually agree to have.