Thursday, March 22, 2012

The distortions caused by "preventive care"

Is over-diagnosis and over-treatment the logical corollary to preventive care? It increasingly appears so, atleast if America is any yardstick for such assessment.

Over the past couple of decades, as health care budgets started ballooning, successive American governments have started focusing attention on preventive care so as to do early diagnosis and limit health care expenditures. Simultaneously, as health care costs started rising, private insurers too faced the same incentives.

An excellent article in the Times points attention to the increasing trend of conducting recurrent diagnostic screening on healthy individuals for various medical conditions. In the United States, healthy men are regularly screened for prostate cancer and healthy women for breast and cervical cancer.

In the past, doctors made diagnoses and initiated therapy only in patients who were experiencing problems... But increasingly we also operate under the early diagnosis precept: seeking diagnosis and initiating therapy in people who are not experiencing problems. That’s a huge change in approach, from one that focused on the sick to one that focuses on the well... in the past, you went to the doctor because you had a problem and you wanted to learn what to do about it. Now you go to the doctor because you want to stay well and you learn instead that you have a problem.

The article highlights the negative effects of such screenings and claims that it results in needless appointments, needless tests, needless drugs and needless operations,

This process doesn’t promote health; it promotes disease. People suffer from more anxiety about their health, from drug side effects, from complications of surgery. A few die. And remember: these people felt fine when they entered the health care system.

In the past, doctors used their clinical skills extensively to make diagnosis. However, for a variety of reasons, doctors today prefer to exercise their clinical skills only after examining the results of an array of diagnostic tests. This elevation of evidence from diagnostic tests to clinical acumen has, apart from dramatically increasing medical care costs, generated several incentive distortions in a market already riddled with information asymmetry and moral hazard.

I am inclined to believe that there are broadly three factors which have contributed towards this trend towards over-treatment and over-diagnosis. One, diagnostic and treatment technologies have improved dramatically over the past two decades thereby enhancing the possibility of successful detection and cure. Second, faced with the increasing prospect of malpractice litigation and patient demand to undergo all diagnostic tests, doctors prefer the easier way out and prescribe the full range of diagnostic screening before their diagnosis. Finally, as I have blogged earlier, the nature of medical insurance has eliminated any incentive among both doctors and patients to optimize diagnostic testing.

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