When the actress, comedienne, and blonde bombshell Mae West observed that “too much of a good thing can be wonderful,” she was talking about sex, not stents. But, unlike sex, “too many stents can kill you,” as Shirlee Peterson observed after her husband, Bruce, died with 21 of them in his chest.1
Surprisingly, 21 stents is not even close to the record. Another patient treated by the same physician—a Texas cardiologist named Dr. Samuel DeMaio—had 31 stents implanted.2 In this patient, the stents reportedly ran more than two feet in length.3 That’s what, in a bit of dark humor, interventional cardiologists call “a full metal jacket.”4 According to Dr. Ralph Brindis, a past president of the American College of Cardiology, the average number of stents per patient is 1.2 to 1.4.5
A stent is a cylinder of fine metal mesh that helps keep open a blood vessel that was previously blocked by cholesterol plaque. Typically, a cardiologist snakes a balloon-tipped catheter to the site of the blockage and then inflates it to compress the plaque. This procedure opens the artery but also weakens it. To prevent the weakened artery from collapsing, the cardiologist then inserts a stent. There are different stents for different places in the vascular system—from the coronary arteries in the heart to the peripheral arteries spread throughout the body. Typically, cardiologists work on the blockages involving the heart, whereas interventional radiologists handle the peripheral arteries. After patients receive stents, they must take blood thinners for the rest of their lives. Otherwise, blood clots may form causing heart attacks and strokes. In the medical literature, the process of inserting a stent is known as percutaneous cardiac intervention (PCI).
The Petersons relied on Dr. DeMaio to determine whether Bruce needed a stent and to insert one if he did. This created a conflict of interest. Dr. DeMaio stood to make more money—a lot more—by recommending an aggressive treatment (stenting) rather than by advising Bruce to use diet, exercise, or medications. The low-tech approach might have been the right strategy for Bruce, but it would have required Dr. DeMaio to pass up a lucrative opportunity.
This conflict of interest did not distinguish Dr. DeMaio from the tens of thousands of other doctors who diagnose patients and then treat them. All physicians who perform both services can have conflicts. What distinguishes Dr. DeMaio and other interventional cardiologists from other doctors is that the financial stakes in their conflicts are much larger. “Stenting belongs to one of the bleakest chapters in the history of Western medicine,” says Nortin Hadler, a professor of Medicine at the University of North Carolina at Chapel Hill, because “the interventional cardiology industry has a cash flow comparable to the GDP of many countries.”6
Most of the revenue that stenting generates goes to the hospitals where the procedures take place. The doctors who perform these procedures receive a separate fee that averages about $1,000.7 That may not sound like much, but it is roughly four times the fee a physician receives for advising a patient to use diet, exercise, and medication.
The monetary incentive to overtreat does not end there. Because cardiac procedures are so lucrative, hospitals use directorships, consultancies, and other made-up arrangements to reward doctors who refer patients or perform these procedures.8 In combination with the base payment, this creates a large incentive for cardiologists to implant stents, even when they are not necessary.
Don’t think that doctors would stick devices into people who don’t need them? Think again. According to a Bloomberg News article, “Two out of three elective stents, or more than 200,000 procedures a year, are unnecessary.”9 The article cited Dr. David Brown, a cardiologist at Stony Brook University School of Medicine in New York, as authority, and he should know. In 2012, Brown coauthored a meta-analysis of eight clinical trials that collectively compared over 7,000 patients with stable coronary artery disease (CAD), some of whom received stents while others received only much cheaper medicines. The conclusion? In patients with stable CAD, there was no evidence that stents were superior to medical therapy for preventing death, nonfatal heart attacks, unplanned revascularizations, or angina.10
In 2014, Dr. Brown published a second study. This one assessed the relative efficacy of stents plus medication versus medication alone for patients with stable CAD and reduced blood flow to the heart, a problem known as ischemia. The 2014 meta-analysis examined the results of five clinical trials that collectively involved over 4,000 patients. Again, stents conferred no benefit. Ischemic patients who received stents weren’t less likely to die or suffer nonfatal heart attacks, unplanned revascularizations, or angina, compared to those who only took medication.11 The COURAGE study, published in 2015, which tracked ischemic heart disease patients for 15 years, confirmed these findings.12
The financial cost of implanting stents in hundreds of thousands of patients who don’t need them reportedly runs to about $2.4 billion a year.13 That’s just for the stents. To calculate the total cost, you’d have to add in the millions upon millions of dollars spent on blood thinners and medical monitoring, and then subtract the (far more modest) cost of medical management of those who did not receive stents. If we count only the direct costs, $2.4 billion isn’t that large a number in the scheme of overall spending on health care—but, as Sen. Everett Dirksen (R-IL) famously observed, “a billion here, a billion there, and pretty soon you’re talking about real money.”14
To their credit, interventional cardiologists have begun to get the overuse of stents under control. From 2009 to 2014, the number of inappropriate nonacute PCIs declined.15 But problems persist. For example, every year thousands of asymptomatic patients undergo PCI as a precaution before being operated on for noncardiac maladies, even though mounting evidence shows that the procedure does them no good.16
Shirlee Peterson claimed that an excessive number of stentings killed her husband. Dr. DeMaio disagreed and claimed to have treated Bruce appropriately. Their dispute figured in an investigation by the Texas Medical Board (TMB). Initially, the TMB filed a complaint asserting that the many “unneeded stents” caused various complications, and ultimately resulted in Peterson’s death.17 The TMB’s complaint alleged that Dr. DeMaio had mistreated an additional eight patients during the same time period (2008–2009) by placing multiple stents in areas of insignificant or moderate disease; that he performed multiple angiograms in patients who were asymptomatic and had normal stress tests; and that he had unnecessarily implanted cardiac defibrillators in two patients.18
The TMB ultimately walked back most of its allegations. According to a news report, it found that DeMaio “placed multiple, elongated, overlapping drug-eluting stents in areas of insignificant or only moderate disease, and that his ‘reading of angiography film as it relates to percentage of arterial occlusion was flawed.’”19 However, the board did not revoke Dr. DeMaio’s medical license. Nor did it impose much of a penalty. Instead, Dr. DeMaio agreed to undergo 30 hours of continuing medical education (including 5 hours on ethics) and 2 years of oversight by another physician, plus a $10,000 penalty.20 The TMB did not report DeMaio to the National Practitioner Data Bank, which tracks doctors who commit malpractice or are disciplined. In the end, Dr. DeMaio was left free to continue practicing cardiology in Texas.
When it comes to stenting, the worst offenders fill a rogues’ gallery. In 2011, a jury convicted Dr. John R. McLean of defrauding Medicare, Medicaid, and private insurers by inserting unnecessary cardiac stents, ordering unnecessary tests, and making false entries in patients’ medical records. Investigators alleged McLean performed more than 200 unnecessary stent procedures at the Peninsula Regional Medical Center (PRMC) and falsified patients’ records to cover up the fraud. Dr. McLean surrendered his medical license and was sentenced to a prison term of eight years. PRMC paid $2.8 million to settle federal claims stemming from McLean’s actions.21
McLean was one of two Maryland cardiologists who were under investigation at the same time. The other was Dr. Mark G. Midei, a staff cardiologist at the St. Joseph Medical Center (SJMC) in Towson. Like McLean, he pulled in an enormous income by performing hundreds of unnecessary heart procedures and falsifying medical records to cover his tracks. After his misdeeds were discovered, SJMC suspended his practice in May 2009. Then, in January of the following year, SJMC sent letters to almost 600 patients, informing them that they might have been stented unnecessarily. The disclosure precipitated a flood of lawsuits, most of which SJMC and Colorado-based Catholic Health Initiatives (CHI), its former parent company, eventually settled.22 According to one news report, CHI agreed to pony up $37 million to settle a class action that may have included as many as 273 former patients, after having previously settled 242 pending cases for an undisclosed amount.23 Some cases appear to have been resolved individually as well. SJMC also agreed to pay $22 million to resolve claims that it had paid kickbacks to MidAtlantic Cardiovascular Associates, the private medical group that employed Midei before SJMC lured him away.24
Midei’s story is interesting for other reasons. Between 1984 and 2009, Midei performed 40,000 cardiac procedures but was never sued by a patient for performing an unnecessary implantation. The malpractice system completely failed to identify him as a bad actor, much less to deter him. So much for the claim that patients and their greedy contingent-fee lawyers will sue doctors over even the tiniest mistakes.
The government agency in Maryland that licenses physicians also recognized the problem far too late. Although it began receiving complaints about Midei in November 2008, it didn’t revoke his medical license until 2011, a full year after the scandal broke.25 In context, this tardiness isn’t all that surprising. State medical boards rely on complaints from patients, malpractice settlements, and disciplinary actions by other states to signal the need to investigate bad doctors. Midei’s patients weren’t complaining or suing—because they didn’t know their stents were unnecessary—so he flew under the radar.
The case also illustrates how valuable doctors like Midei are to the hospitals at which they practice. SJMC recruited Midei in 2008 by tripling the $600,000 salary he was pulling down at MidAtlantic Cardiovascular Associates. That’s how lucrative interventional cardiology can be. SJMC wouldn’t have paid Midei almost $2 million a year unless he was generating revenues far in excess of that for the hospital. After Midei’s suspension was publicized, the volume of implanted drug-eluting stents dropped by 45 percent at SJMC, and by 6–20 percent at other hospitals in Baltimore.26
Midei also had a cozy relationship with stent-maker Abbott Laboratories, which spent over $2,000 for a barbeque at his house that included “a whole smoked pig and other fixings.” The cause for celebration? Midei had implanted 30 of Abbott’s stents in one day, “perhaps setting the single day implant record,” according to an unnamed Abbott official.27 If that’s not a clear conflict of interest, nothing is. Abbott also displayed its gratitude by hiring Midei as a consultant after SJMC let him go.28
Another scandal involving unnecessary stents occurred at a second St. Joseph Hospital (SJH) that was also owned by CHI but located in London, Kentucky. This time, the surgeries at issue were performed by a team of cardiologists led by Dr. Sandesh “Sam” Patil. After hundreds of patients filed lawsuits accusing Patil of inserting stents they did not need, the Kentucky Medical Licensure Board examined the records for five patients and found that he “plac[ed] stents without justification in three of them.” Eventually, Patil pled guilty to criminal charges, admitting that he had made false statements about patients’ medical conditions so he could be paid for inserting stents in them. His plea deal called for a prison term of 30 to 37 months.29
As in Baltimore, the number of stenting procedures that were performed at SJH dropped dramatically after the scandal became public. According to University of Louisville professor emeritus Dr. Peter Hasselbacher, before news of the lawsuits broke, SJH did more angioplasties with stents than either of Kentucky’s two major teaching hospitals. Subsequently, “the number of invasive procedures dropped by one-third, which [Hasselbacher] called ‘the most persuasive evidence that too many cardiac catheterizations with placement of stents might have been performed.’”30
If two of every three elective stents are implanted needlessly, it should come as no surprise that many more physicians than we can mention here have been accused of overstenting. Skipping over many convicted offenders, we award the Worst-of-the-Worst to Dr. Najam Azmat and the folks at the Satilla Regional Medical Center who hired him.31 When the two cardiologists who formerly did stenting procedures at Satilla started taking their patients elsewhere, Robert Trimm, Satilla’s CEO, brought in Azmat by offering him a guaranteed salary of $600,000 in his first year plus a signing bonus of $25,000.32 The compensation was lavish, supposedly because surgeons had to be paid extra to move to tiny Waycross, Georgia, the bit of Okefenokee swampland that Satilla called home.
Azmat had completed a surgical residency, but he had almost no experience with stents. When he applied for the position at Satilla, “his only hands-on training in stents consisted of two weekend courses practicing on cadavers and pigs.”33 After accepting the job, he attended a two-day class during which he implanted at least two stents in the renal arteries of live humans.
Things went badly from the start. Nurses who worked with Azmat saw that he didn’t know which catheters to use, what their names were, or how they worked. After her second surgery with him, nurse Lana Rogers told both Trimm and Harmon Raulerson, the manager of Satilla’s Heart Center, that Azmat’s lack of training was obvious. Hospital administrators had no interest in stepping in; when one “nurse asked a hospital official if ‘someone was going to have to die before we can stop Azmat,’ the official responded, ‘yes’ or ‘probably’. . . .”34
Unfortunately, Azmat didn’t learn on the job either. A former patient who was a professor of radiology at Duke University sued Azmat for placing a stent in the wrong leg.35 Quality experts call that type of “wrong-site surgery” a “never event,” because it’s never supposed to happen. It took four attempts for Azmat to insert a stent into the leg of another patient, Norman Copeland.36 Even when he eventually succeeded, Azmat used the wrong stent and caused the patient considerable pain. There were also serious questions about whether the procedure was necessary in the first place.37
The cascade of mistakes led the nurses to revolt. They threatened to quit if they were asked to work with Azmat again.38 The hospital suspended Azmat’s privileges for 10 days, but he returned to implanting stents thereafter.
Azmat subsequently treated Ruth Minter, a mother of five who had been suffering from pain in her back and stomach. He recommended a stent to improve the flow of blood to her kidneys. During the procedure, he botched the insertion and penetrated the wall of her right kidney. This led to internal bleeding and an airlift to a Florida hospital, where Minter underwent emergency surgery. To no avail. Seventeen days later, she died of hemorrhagic shock and multiple organ failure. According to the Department of Justice, which intervened in a whistleblower lawsuit filed by nurse Rogers, the procedure that Azmat performed on Minter “was not medically indicated,” meaning it should never have been performed.39
Her case was hardly unique. “Federal investigators found more than 30 patients who received ‘worthless,’ poor or unnecessary care from Azmat, according to experts’ case reviews and other documents filed in federal court.”40 A U.S. Department of Justice lawyer reportedly said in open court that Satilla’s “administrators knew Azmat wasn’t qualified, yet allowed him to keep working, ‘profiting all along the way with the lucrative hospital service claims it received in connection with those procedures.’”41 Satilla paid $840,000 to resolve the federal case. The hospital also settled for undisclosed amounts with Minter’s family and seven other patients who sued for medical malpractice.42
As for Azmat, his privileges were eventually suspended by Satilla, and he resigned from the hospital after his professional liability insurer wisely refused to renew his malpractice coverage.43 He then took up work at a pain clinic in Lexington, Kentucky, where he reportedly earned $7,500 a week prescribing narcotics. He was suspended from participating in Medicare and other federal health insurance programs in May 2012. In 2013, he was arrested for running a pill mill in Garden City, Georgia. He was convicted in 2014 and sentenced to 11 years and 1 month in prison. He was nicknamed “Dr. Hazmat” in the federal indictment.
Azmat’s case exemplifies the inability of state licensing boards to protect patients from dangerous physicians.44 Although he began harming patients in the mid-1990s, Azmat wasn’t convicted and punished for his crimes until 2014. In 1997, the Hardin Memorial Hospital in Elizabethtown, Kentucky, where Azmat worked early in his career, restricted his privileges after finding that patients involved in 23 percent of his surgeries experienced intraoperative or postoperative complications.45 Azmat had also been named as a defendant in three different malpractice cases before he joined Satilla’s staff in 2005. As noted above, Satilla suspended his privileges for 10 days in 2006. Next there was a flood of fraud allegations and malpractice suits relating to Azmat’s actions at Satilla. Despite the many warning signs, however, all three of the states in which Azmat was licensed—Indiana, Kentucky, and Georgia—let him continue treating patients.
Kentucky finally yanked Azmat’s license in 2012, when a local emergency room doctor ratted him out for prescribing dangerous drugs.46 Indiana followed suit the same year. But Georgia, the state where all the dangerous and unnecessary stenting occurred, didn’t do anything until 2013, and its medical board acted only after an article published in Modern Healthcare lampooned the board for letting him keep his license after he was arrested and jailed.47
It is clear there is an epidemic of unnecessary stenting, but it is equally clear that there are also millions of patients whom stents have helped, many by saving their lives. For example, a 2013 study that focused on high-risk CAD patients concluded that those who received PCI plus medical treatment died far less often than those who received medical treatment alone.48 The problem of distinguishing between necessary and unnecessary stenting is simple to state but hard to solve. The line between appropriate and inappropriate treatments doesn’t draw itself. It depends on the expected benefits of a treatment and whether they exceed the expected costs, and the answer will vary from patient to patient. Unfortunately, our politically controlled, third-party payment system leaves most of that information with cardiologists and hospitals, on whom the system lavishes money only when they perform aggressive procedures and regardless of the consequences for patients. Stented patients may experience no improvement or even die; our politically controlled, third-party payer system cuts the checks regardless. The predictable result is that many doctors overstent and too many patients wind up with full metal jackets.
Paying for every service a physician recommends has served the medical profession well in financial terms, but it has also led to waste, fraud, and abuse. In too many cases, it has led to injury and death too. We’ve focused on stents, but problems with excessive cardiac treatments are very old news. “Long before the first unnecessary-stent charges started making headlines across the [United States], cardiology leaders ha[d] been warning their peers that if they didn’t start policing their own ‘appropriate use’ of devices and procedures, someone else was going to step in to do it for them.”49
Outsiders took over the job of policing misconduct at the Redding Medical Center (RMC) in Redding, California. Acting on a tip from a patient who claimed that physicians at the hospital were performing unnecessary angiograms, cardiac artery bypass graft surgeries (CABG—pronounced “cabbage”), and heart-valve replacements, the FBI raided the hospital in October of 2002.50 The evidence gathered then and during subsequent lawsuits supported allegations that two RMC doctors, Chae Hyun Moon and Fidel Realyvazquez Jr., performed unnecessary but highly profitable cardiac procedures on over 750 patients. Medicare reportedly paid RMC more than $300,000 for each CABG surgery. The surgeries were thought to have killed at least 94 patients and to have caused many others to suffer strokes, paralysis, and heart attacks.51
The scandal at RMC received substantial press attention, including an expose on 60 Minutes, and was eventually covered at book length.52 The doctors contested the allegations and neither went to jail, but the U.S. Department of Health and Human Services told Tenet Health Care Corporation, the owner of RMC, that it would discontinue federal funding unless Tenet sold the facility. Tenet complied and forked over $369 million to settle with 769 patients who claimed to have been victims of unnecessary cardiac surgeries, plus another $54 million to resolve fraud investigations by public regulators.53 At the time, the latter was the largest penalty for overbilling in history.
As for the surgeons, Dr. Moon’s cardiology group kicked in $24 million to the civil settlements, and Moon himself stopped practicing medicine. Realyvazquez entered into a deal with the California Medical Board pursuant to which his license was revoked then immediately reinstated with a three-year probationary period, during which he was required to receive training in ethics and medicine and to be supervised by other physicians.54
It’s hard to know which is more shocking: that so many people were mistreated at RMC or that Medicare and other payers just kept on paying for procedures that were harming patients. At the height of its operations, RMC’s cardiac surgery unit was performing procedures at a fantastic rate. In one 12-month period, Moon charged Medicare for 876 left-heart catheterizations, four times the rate of the next-highest cardiologist in Northern California. Medicare paid Moon more than every other cardiologist in Northern California except one.55
RMC benefited greatly from Moon’s stellar work ethic. In the fiscal year that ended June 30, 2002, RMC generated pretax net income of $94 million, the most of any of Tenet’s 40 California hospitals.56 Over the same period, the Mercy Medical Center, a larger hospital located near RMC, generated pretax net income of only $5 million. Even so, the bureaucrats who run the Medicare program sat on their hands. Their job was to pay claims, not to second-guess providers’ actions.
Having discussed the overuse of stents and other interventional cardiac procedures, we should also mention two recent studies, the first of which showed that “less is more” for seniors in a way that would be comical if it weren’t so sad. Cardiologists have two big conventions a year: the annual meetings of the American Heart Association and the American College of Cardiology. Because so many physicians attend these meetings, hospitals have fewer doctors available to serve patients who come in with acute cardiac conditions like heart attacks and cardiac arrest when the conventions are in progress.
A clever group of researchers compared the 30-day all-cause mortality rates for Medicare recipients with these problems who were admitted to hospitals during the conventions to those for patients who were admitted three weeks before and three weeks after the conventions. The latter groups were treated when the hospitals’ staffs were at full force. The researchers “hypothesized that mortality would be higher . . . during the cardiology meeting dates” and “that differences in outcomes would be largest in teaching hospitals, where a disproportionately larger fraction of cardiologists may attend cardiology meetings.”57
To their surprise, patients suffering from heart failure or cardiac arrest who showed up at major teaching hospitals while the conventions were underway fared better than those who arrived on other dates. Their 30-day mortality rates were lower, not higher, when fewer doctors were in town. Why? Although the researchers qualified their answers carefully, the most plausible explanation was “that the intensity of care provided during meeting dates [was] lower and that for high-risk patients with cardiovascular disease, the harms of [more intensive] care may unexpectedly outweigh the benefits.”58 High-risk patients fared better when doctors at teaching hospitals were off at meetings because they received less care.
The second study, known as ORBITA, appeared just as we were wrapping up this book. Wanting to quantify the impact of stents on patients with stable angina (ischemic chest pain) and severe single-vessel stenosis (narrowing) of a cardiac artery, ORBITA divided 200 patients randomly into two groups. One group received stents. The other underwent a “sham procedure,” which fooled people into thinking they had stents implanted, even though they did not. This enabled the researchers to control for placebo effects. When researchers tested members of both groups six weeks after their procedures, they found no discernible differences between the two groups in terms of chest pain, ability to exercise on a treadmill, or a host of other measures.59 Stated differently, in patients with stable angina and single vessel disease, the placebo worked as well as the stents.
In a commentary on the study, Drs. David L. Brown and Rita F. Redberg observed:
First and foremost, the results of ORBITA show unequivocally that there are no benefits for PCI compared with medical therapy for stable angina, even when angina is [resistant] to medical therapy. Based on these data, all cardiology guidelines should be revised to downgrade the recommendation for PCI in patients with angina despite use of medical therapy.
Brown and Redberg titled their piece “Last Nail in the Coffin for PCI in Stable Angina.”60 At least one cardiologist got the message. The New York Times reported that Dr. Brahmajee K. Nallamothu, an interventional cardiologist at the University of Michigan, coincidentally had a stenting procedure to open a blocked artery scheduled for the day he happened to read the study. Nallamothu found the study’s results so convincing that he canceled the procedure. “I took him off the table,” Nallamothu said.61
Despite Nallamothu’s example, we wish we shared Brown’s and Redberg’s optimism that cardiologists will stop performing PCI for stable angina now that ORBITA has made it crystal clear that less can be more. So long as cardiologists have an economic incentive to use (and overuse) stents, we expect many of them will continue to do so, despite the fact that those stents increase the risk of “death (0.65%), myocardial infarction (15%), renal injury (13%), stroke (0.2%), and vascular complications (2–6%).”62 If we want cardiologists to change their behavior, we should change their incentives.
It may seem like we have something against cardiologists. Not so. We admire cardiologists and owe them dearly. A few years ago, a cardiologist who specializes in electrophysiology saved one of our lives. We are grateful and have no wish to seem otherwise.
We had an abundance of specialties from which to choose. Instead of concentrating on cardiologists, we could’ve written about unnecessary back surgeries,63 or the efforts orthopedic surgeons made to close down the Agency for Health Care Policy and Research when it came out with treatment guidelines that would have required fewer lucrative interventions and more “watching and waiting” for patients to heal.64 We could have focused on dentists, some of whom have conducted unnecessary “mass production” procedures on poor children to maximize Medicaid payments.65 We could have examined doctors who treat cancer patients, many of whom perform unnecessary tests and procedures on seniors who are too old to benefit.66 They also prescribe drugs that cost tens of thousands of dollars to administer but that have never been shown to extend or improve patients’ lives.67 We could have focused on physicians who admit patients to intensive care units (ICUs) because, in one study, more than half the patients at an academic public hospital’s ICU could have been cared for in a less expensive setting and were unlikely to benefit from ICU care.68 We could have reported on the fact that physicians who treat patients for stenosis of the carotid artery perform surgery far more often than guidelines recommend, and far more often when compensated on a fee-for-service basis than when paid a salary.69 The subtitle of a 2017 article copublished by ProPublica and the Atlantic tells the story of excess in American health care: “Years after research contradicts common practices, patients continue to demand them and doctors continue to deliver. The result is an epidemic of unnecessary and unhelpful treatment.”70
We focused on cardiologists for the reason we identified at the start. Compared to most other physicians, they have larger conflicts of interest because they recommend and perform big-ticket procedures that generate enormous revenue flows. The “cath labs” and operating theaters where cardiac procedures are performed generate substantial fractions of many hospitals’ net profits. This is why hospitals pay interventional cardiologists fabulous salaries71 and enter into sweetheart deals that compensate outside cardiology groups for referrals.72 Not surprisingly, the pressure to perform procedures is intense. It is to the profession’s credit that cardiologists resist the pressure as often as they do; but, given the strength of the incentive to overtreat, a high rate of unnecessary procedures is inevitable. Bad incentives corrode good judgment.
Let there be no mistake: doctors have plenty of freedom to recommend unnecessary treatments. The vast majority of medical decisions involve subjective judgments. Sanjaya Kumar, chief medical officer at Quantros, and David B. Nash, dean of the Jefferson School of Population Health at Thomas Jefferson University, explain:
Reams of research point to the same finding: physicians looking at the same thing will disagree with each other, or even with themselves, from 10 percent to 50 percent of the time during virtually every aspect of the medical-care process—from taking a medical history to doing a physical examination, reading a laboratory test, performing a pathological diagnosis and recommending a treatment. Physician judgment is highly variable.
Give a group of cardiologists high-quality coronary angiograms (a type of radiograph or X-ray) of typical patients and they will disagree about the diagnosis for about half of the patients. They will disagree with themselves on two successive readings of the same angiograms up to one-third of the time. Ask a group of experts to estimate the effect of colon-cancer screening on colon-cancer mortality and answers will range from five percent to 95 percent.
Ask fifty cardiovascular surgeons to estimate the probabilities of various risks associated with xenografts (animal-tissue transplant) versus mechanical heart valves and you’ll get answers to the same question ranging from zero percent to about 50 percent. (Ask about the 10-year probability of valve failure with xenografts and you’ll get a range of three percent to 95 percent.)
Give surgeons a written description of a surgical problem, and half of the group will recommend surgery, while the other half will not. Survey them again two years later and as many as 40 percent of the same surgeons will disagree with their previous opinions and change their recommendations. . . .73
Given the uncertainty that attends medical assessments, it is critical for doctors to be unconflicted when diagnosing patients and recommending treatments—particularly when they will perform the treatments they recommend. But existing compensation arrangements create strong conflicts that incline doctors to recommend more treatments than patients need. The result is an epidemic of overuse that kills tens of thousands of patients, injures hundreds of thousands of others, and wastes perhaps a trillion dollars a year. And the blame rests with a politically controlled third-party payment system, which is designed to move as much money as possible to health care providers and won’t let qualms about corrupting doctors’ integrity stand in the way.