Bill Bestermann, MD, Medical Director at QualityImpact (COSEHC) Practice Transformation Network in Greenville, South Carolina, has spent the past few years training other physicians to optimize the care of patients with cardiometabolic disease. In a project sponsored by Louisiana Blue Cross, Dr. Bestermann worked with 700 primary care physicians to improve care and outcomes for patients with multiple risk factors. In 3.5 years, the percentage of hypertensive patients who achieved their goals rose from 47% to 67%, a 42.5% increase. Even more noteworthy, diabetics reaching their goals rose from 14% to 30%, a 114% improvement.
These results are clearly strong, no question. But most striking is that the treatments Dr. Bestermann advocates for are based on solidly established science. They have been disregarded, not because most physicians don’t believe in science, but because healthcare’s scientific foundation has been trumped by financial incentives.
Dr. Bestermann’s most difficult ethical dilemma
A few days ago Dr. Bestermann shared a short response he had written to an ethics survey that, among other questions, asked this: “What is the most difficult ethical dilemma that you have faced in your career?” He wrote:
“A mountain of evidence shows that, in stable angina patients, optimal medical therapy (OMT) alone—simple application of proven drugs and lifestyle changes rather than surgical interventions—is as effective as OMT plus a stent. After a heart attack, OMT compared with usual care saves $22,000 per patient per year while reducing cardiovascular- and all cause-mortality 10-fold. In patients with type 2 diabetes, OMT reduces heart attack 4-fold, reduces stroke 5-fold, and reduces dialysis 6-fold. Louisiana Blue Cross has shown that, with the proper support, ordinary practices can easily produce OMT. Despite irrefutably strong evidence, financial incentives continue to dominate, framing bypasses and stents as answers.
The pervasiveness of inappropriate care is our medical system’s biggest ethical stain. We harm by delivering high-risk care that patients should not receive and by not providing the safe inexpensive care they should receive. This ethical collapse is everywhere, occurring every day in every state. We violate that fundamental medical aphorism ‘First do no harm!'”
This is a remarkable and heartrending statement, and all the more damning from a respected and field-experienced physician. It articulates the profound frustration of a doctor who puts patients’ welfare first, and whose confrontation with medicine’s “ethical collapse” is professionally and personally excruciating.
The excesses in cardiology permeate every clinical and financial sector of healthcare. For example, musculoskeletal care is about 20% of group health and 60% of occupational health spending, or between 4.0-4.5% of the U.S.’ gross domestic product. Comparative international data and evidence from best practice studies show that U.S. healthcare organizations deliver about double the musculoskeletal care of those in other industrialized countries. In other words, just the inappropriate care we deliver in this field is equal to more than 2% of the entire U.S. economy. A breathtaking figure and an indictment.
Squeezing out the waste
These problems are also opportunities. A U.S.-based musculoskeletal management company delivers better pain reduction, improved Activities of Daily Living, and improved range of motion in half the recovery time and at 60% of the cost of conventional orthopedic care. Oncology management companies are driving out 20-35% of cancer care costs, with improved health outcomes and better reported patient experiences. Companies focused on unnecessary drug spending are reducing those costs by 30% with improvements to quality and access. There are similar stories for surgeries, hospital costs, dialysis, hemophilia, management of high-cost cases, primary care, imaging, and on and on. Mainstream healthcare can be delivered with far better health outcomes and much lower costs.
The rub is that reduced costs are counter to financial interests of the industry’s powerful stakeholders, and so the industry has been resistant to these better approaches. The good news is that unions and employers are demanding greater value, lending increased traction to high-performance firms. As excesses continue and purchaser pushback intensifies, opportunities to exploit the market’s vacuums will blossom, driving approaches that realign healthcare with our ethical aspirations.