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Too much healthcare can be hazardous to your health, as three findings released last week have shown.
- America’s Epidemic of Overtreatment
Health Affairs reports an epidemic of overtreatment. Author Shannon Brownlee proposes that patients “start asking uncomfortable questions,” to determine if treatments are appropriate. The problem is that employees don’t know what uncomfortable questions to ask, unless one counts: “Do you mean to say I’m not eating enough broccoli?” The questions don’t have to be uncomfortable. They get more comfortable, the more one learns about healthcare. Seems simple enough, and yet 99% of employers still don’t offer employee healthcare literacy education.
2. America’s Epidemic of Innumeracy
It would help if doctors knew the first thing about interpreting lab test results before recommending these treatments, but apparently they don’t. The Washington Post reports that professionals reading lab test results don’t understand false positive arithmetic. As a result, your employees may be getting diagnosed and treated for conditions they don’t have. Wellness vendors don’t understand it either. As compared to real medical professionals, the difference is that the they take great pride in their ignorance, and brag about how many false positives they find. I’m talking to you, Interactive Health.
No, they don’t. We’ll post on false positive arithmetic next week.
3. America’s Epidemic of Overprevention
As reported on They Said What Thursday, it looks like too much spending on prevention can backfire. Specifically, spending more on employee healthcare, and sending more employees to the doctor, does not deliver better outcomes, fewer ER visits, or even more HbA1c checks for diabetics. Quite the contrary, the correlation, though weak, goes in the “wrong” direction.
Bottom line: looks like Quizzify had it right all along: just because it’s healthcare doesn’t mean it’s good for you.
They Said What has always noted the complete and utter worthlessness of screening the stuffing out of employees. The wellness vendor response to this observation? To double down on overscreening. One recalls the immortal words of the great philosopher Inspector Louis Renault: “Owing to the seriousness of this crime, I’ve instructed my men to round up twice the number of usual suspects.”
Here is one such vendor, the lucky recipient of a follow-up profile to be published next month.
Their litany of tests before my initial observations about their overscreening were published:
Their current roster of tests, setting a new wellness industry record:
However amusing it may be to remark on the rampant epidemic of very stable genius-itis in the wellness industry (and it is), screening the stuffing out of employees is no laughing matter. It is harmful. Here is the current Journal of the American Medical Association on the harms of screening. Unfortunately the entire article is behind a paywall, but the abstract basically highlights the wellness industry business model:
Overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop.
This is of course exactly what hyperdiagnosis is all about — and the poster child for hyperdiagnosis is none other than the winner of the 2017 Deplorables Award, Interactive Health. A single Interactive Health display captures it all, the breathless braggadocio about sending employees to the doctor because they flunked one or more of the 43 tests that Interactive Health runs, with no regard for the harms that JAMA has identified:
So, in all seriousness, can we please, please stop the hyperdiagnostic madness and start screening according to the US Preventive Services Task Force guidelines?
The wellness industry is the Maginot Line of workplace health. While wellness vendors are imploring employees to eat more broccoli, and hyperdiagnosing the stuffing out of them to find “newly discovered” conditions that are mostly false positives and harmless out-of-range readings, really bad stuff has been happening that has somehow eluded this industry’s attention. One would be the opioid epidemic, which no vendor seemed to notice. Except Optum, whose HRA basically advises employees to get more pills for their pain.
(Do you know more than Optum does about opiods Take this quiz and find out.)
The other would be the explosion of harms caused by the healthcare industry itself, and that is the subject of The Bleeding Edge, a well-received new documentary (Rotten Tomatoes rating: 89%) on Netflix. (In case anyone is keeping score at home, Quizzify is also about harms caused by the industry…and already educates employees to avoid most of what The Bleeding Edge covers.)
The Bleeding Edge follows victims of three different kinds of implants — vaginal mesh made by Johnson & Johnson, metal-on-metal hips made by Johnson & Johnson (are you seeing a trend here?), a birth control device financed in part by the current head of the FDA — along with briefer cameos for CAT scans and the DaVinci robot.
Interviews of victims of these implants (including one who started out as a spokesperson for these implants) are intertwined with surgeries and images of devices gone haywire inside the victims’ bodies, and expert talking heads about how this could be allowed to happen. (“More evidence is required to remove a device than to approve it.”) The experts are very well-credentialed and include the long-time head of the FDA, David Kessler, and bestselling author and Johns Hopkins accountability guru, Dr. Martin (“I love what Quizzify is doing”) Makary.
Perhaps the most compelling interview, though, is with the aforementioned former spokesperson for the birth control device-turned-victim advocate. Switching sides like this never happens. Most people pick a side and stay on it, facts be damned. Switching sides after seeing new facts is almost unheard of — it would be like Ron Goetzel not only admitting that wellness doesn’t work, but blowing the whistle on his friends at Wellsteps and Interactive Health.
The difference was that this spokesperson was also a customer…until her device went badly astray as well.
What is the FDA doing about this?
So what, as the film describes, is the FDA doing to put the kibosh on all this? Four things:
- Facilitating approvals of new devices on almost no evidence
- Laughing out loud on videotape at the idea that they may get in trouble because some people could get harmed
- Hiring industry executives to regulate their friends and companies they have invested in
- Firing experts who advocate for disclosures of hazards.
Yes, we know it isn’t always about Quizzify but #4 specifically relates to the hazards of CAT scans. The FDA apparently fired nine employees for advocating what we here at Quizzify have educated patients on — right on our landing page quiz — for three years: the radiation hazards of CT scans, especially repeated scans. Your doctor isn’t telling you about this risk possibly because everyone at the FDA who would have told them is gone.
Likewise, the FDA takes a hands-off approach on the DaVinci robot, another Quizzify whipping boy, though we weren’t the first to question their integrity. The FDA let the company put the robot into the hands of completely inexperienced surgeons, and multiple cases have been reported in which a woman’s insides literally fell out following the surgery.
Many doctors — especially “leading experts in the field” — get directly or indirectly compensated to use and pitch these devices. Your doctor could be one of them, and it’s not like he or she is going to volunteer the information.
What should employers do?
It seems that the only people who truly advocate for the patient are the patient and the patient’s family. Everyone else involved in the care conversation makes more money when employees buy more things on the employer’s dime. (This is not to say all providers or device manufacturers are corrupt, or anything close to that, of course. But with all this money at stake, shareholders interest and patients’ interest could be at great variance. One need only look at stock prices to see which side usually wins.)
Likely much the opposite of what they are doing now. First, stop obsessing with screens and risk assessments. Prying, poking and prodding doesn’t work, so get over it. Start focusing on things that matter, like the harms described in this film and like what Atul Gawande says:
Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year…Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.
At the very least, employers should slow down before encouraging the opposite, incentivizing employees to use lower-cost settings to get things that they may not need, and may even harm them. Obviously (with the exception of childbirth, which is going to happen anyway), removing the economic disincentive to get more stuff means people will get more stuff.
Instead, educate your employees, using Quizzify or some other tool like Quizzify (good luck finding one), that, as we say at Quizzify and as anyone who watches The Bleeding Edge will say:
Just because it’s healthcare doesn’t mean it’s good for you.
Wellness is about pushing employees into the healthcare system, almost always both against their will and their better judgment. This story is a perfect example of the consequences of how too much healthcare can be hazardous to your health, and why your best defense against overdoctoring is knowledge.
Once you start asking questions, doctors have to start answering them. While many doctors welcome that, others start fidgeting. If your doctor is one of the latter, it’s probably time to switch.
I myself get occasional bladder tumors. Ironically — and once again, showing the unintended consequences of wellness — I got bladder cancer from eating more broccoli, which of course is exactly what wellness programs would have us do. (And which, in all fairness, is generally a good idea.) The problem was that the broccoli was grown in a garden that was way too close to railroad ties, which leach creosote into the soil. Creosote causes bladder tumors.
So every few years, one grows back and has to be scooped out “non-invasively” (that’s easy for the doctor to say). And every year I go in and get checked, also “non-invasively”. After my last check, the urologist — a new one, whom I had never seen before — suggested a CT scan of the kidneys and ureters.
I asked her why, and she said, because I had had bladder cancer for 15 years and never had this scan.
I replied: “Well, I founded a company, Quizzify, that educates on overutilization. CT scans have 500 times the radiation of x-rays, and that particular set of views is likely to spot tumors on my adrenal glands that are completely clinically insignificant, and yet once spotted will be tracked and possibly removed, for no good reason other than that they are there.”
She said: “OK, why don’t we just start with a urinanalysis.”
From a hazardous and likely counterproductive $1000 scan to a $10 urinalysis in 30 seconds. That’s what knowledge is worth.