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Failing Conventionally In Healthcare

From May 2018:

Case One: President Garfield

On July 2, 1881, President Garfield was shot twice. The non-fatal bullet lodged in his abdomen. The President was a VIP and had the “fortune” to get the best medical treatment. Decades before many soldiers had similar bullet wounds and went on to live to old ages. A lodged bullet wound is not a death sentence. The President’s doctors wanted to give him the best treatment and for over two months poked their dirty fingers in his wound so they could find and remove the bullet. Garfield lost 80 pounds during that summer and finally died of sepsis on September 19th. The assassin, who was later put to death, claimed: “the doctors killed Garfield, I just shot him.” His assertion was not completely false. President Garfield’s doctors failed him but they failed conventionally so no one was going to blame them. Do we have to worry about similar poor medicine in modern times?

Case Two: President George W Bush

132 years later, in the summer of 2013, another President was “lucky” enough to enjoy VIP treatment by doctors. President George W. Bush was undergoing a routine stress test where he experienced non-specific EKG changes. He had no symptoms at the time and was in excellent physical shape as evidenced by 60+ mile bike trips. He was “rushed to a nearby tertiary care hospital, where he had a cardiac scan and an urgent PCI (percutaneous coronary intervention, or angioplasty) which included insertion of a coronary artery stent.” According to a group of Harvard cardiologists:

“There are only two reasons for undergoing any treatment: to feel better or to live longer. If you aren’t having chest pain or other symptoms, angioplasty to open a narrowed artery can’t make you feel any better. And the results of COURAGE and other studies show it won’t help you live any longer.”

Fortunately, the President had no obvious complications from the procedure. No doubt he did have to take some medicines as a result of the procedure which would have increased the risk of bleeding and other side effects. The unnecessary procedure also exposed him to unnecessary risk. An angioplasty is not a riskless procedure. No one blamed the President’s doctors because they failed conventionally.

Case Three: Warren Buffett

Buffett had a routine PSA test at the age of 81 to screen for prostate cancer. The U.S. Preventive Services Task Force does not recommend PSA screening test for men over 75 (many experts question the necessity of the test even in younger men). Buffett’s doctors were giving him VIP treatment. They likely reasoned that getting more information by obtaining a non-invasive blood test can only help. More information is better – right? Buffett underwent unnecessary radiation to prevent death from prostate cancer. The treatment was most likely unnecessary as Buffett was unlikely to die from prostate cancer. Buffett’s doctors failed him conventionally. Ironically, one of Buffett’s quotes is:

Failing conventionally is the route to go; as a group, lemmings may have a rotten image, but no individual lemming has ever received bad press

Buffett would readily admit that he, like the rest of us, is not above human foibles. Perhaps that is why he avoids taking part in auctions.

Case Four: Melania Trump

This case is fresh and little details are available. It is likely, however, that Ms. Trump, as a VIP, was subjected to unnecessary diagnostic tests that revealed a benign lesion in her kidney. Perhaps a nonspecific symptom led to imaging studies. Doctors likely wanted to investigate her symptoms and obtained as much information as possible. More information is always better – right? The imaging studies likely found Ms. Trump’s benign lesion in her kidney that led to an embolization procedure and five days of hospitalization. Embolization procedures are not riskless procedures and neither is five days of hospitalization.

The cases above demonstrate the great urge of humans to opt for failing conventionally over succeeding unconventionally. Imagine a different scenario in each of the cases above. What if Garfield’s doctor opted to do nothing about his bullet wound. If Garfield went on to live to an old age, the doctor would certainly not be celebrated for doing nothing. The doctor succeeded but not conventionally. On the other hand, if Garfield died, he likely would have been criticized for not doing more.

What if Bush’s doctor opted to ignore the EKG changes and sent him on a long bike ride instead? If Bush did well, again no one would give the doctor credit for his correct unconventional decision. But if Bush died from a heart attack, he would be open to criticism. What if Buffett’s doctor after witnessing his vibrance and energy and sent him home without any diagnostic tests? Or Melania Trump’s doctors waited before getting imaging studies? Doctors rarely get rewarded for doing nothing even if that is precisely the right thing to do.

The above cases are not just limited to VIPs. Tens of millions of Americans are subjected to unnecessary diagnostic tests and procedures. These people are teachers, company managers, food servers and even doctors. Many take unnecessary prescriptions. In his brilliant book, “Overdiagnosed: Making People Sick in the Pursuit of Health” H. Gilbert Welch elaborates on the harms of overdiagnosis and overtreatment in the US.

The Healthcare Curve

Above is a conceptual depiction of health care outcomes versus expenditures. Individuals lie somewhere along this curve. Today in the US, many policy makers focus on people to the left of point C. These are people whose health would be improved if more money was spent to improve their health. For example, a diabetic or hypertensive individual who cannot afford the cost of her medicines may be at point A. She would likely move to the right closer to the peak of curve if she was provided with appropriate medicines for hypertension and diabetes.

Very little is said about the tens of millions of people to the right of point C. These are people who are receiving too much care which is actually harming them more than helping them. VIPs like President Garfield, President Bush, and Buffett (and most likely Melania Trump) are well to the left of point C. To fully appreciate this point on a national scale, let’s take a look at US’s healthcare expenditures versus outcomes. The chart below shows health care spending per capita for select countries.

The US spends about four times more than Chile and three times more than Italy. There is nothing wrong with spending so much on healthcare. Who is to say what is the optimal amount that a nation should spend in any one industry. With all the spending we should expect and demand superior outcomes however. Below is a chart of life expectancy by country.

To be sure, life expectancy is only one measure of healthcare outcomes. Even by other measures the US, despite its vast health care expenditures, ranks poorly compared to other rich countries. As you can see in the chart above, the US ranks slightly below Chile, a country that spends less than a quarter as much as the US on a per capita basis. Our health care system is like a couple going out to eat and spending $500 to eat a 15-minute meal at McDonald’s. There is nothing wrong with spending $500, nor at eating at a fast food restaurant. But the combination of the amount spent and the dining location demonstrates the flaw in the system.

As a nation, the US is clearly well to the right of point C in the Healthcare Curve. Many point out that the causes for these poor outcomes have little to do with actual delivery of care but more to do with the unique problems in the US such as gun violence and obesity. Those issues are beyond the scope of this post but even if that assertion is correct, the country is misallocating its resources dramatically. Perhaps instead of constant ads for unnecessary medicines, the country needs to make a bigger effort at eradicating the sources of the diseases. No matter what, we as a nation, are misallocating resources.

The US healthcare system is failing its citizens. The government is investing its resources irrationally. As individuals, we have little control over these complex policy issues, but we have complete control over our own bodies. The diagnostic tests or the genetic tests at companies like 23andMe are likely doing more harm than good. Shunning extra medical care and tests is unconventional for sure and in the words of Keynes, “worldly wisdom teaches that it is better for reputation to fail conventionally than to succeed unconventionally.”

The pace and amount of health care spending is unsustainable. The Congressional Budget Office estimates that by 2025 the entire tax revenues will have to be spent on entitlements and interest on debt. The future will not be like the present. What do you think will happen when tax revenues cannot keep up with the government’s promises? Fortunately, the US is in charge of its own destiny unlike Greece that could not print Euros to satisfy its obligations. The US government can print more dollars even if it leads to rampant inflation. Another option for the government would be to raise taxes to meet its obligations. That would likely result in the economy’s contraction at a time when growth would be crucial for servicing the debt. The US will survive the coming crisis as it has in the past, but individual investors should be prepared with the upcoming pain. Inflation has been silent for decades but it is far from slayed.