Two articles in the New England Journal of Medicine caught my eye. Although they appear to address very different subjects, I believe they have an important connection.
The first, which got a lot of press coverage, was a report of a study done in Finland. The authors performed a “multicenter, randomized, double-blind, sham-controlled trial” exploring the utility of arthroscopic meniscectomy in patients 35-65 years old who all had knee pain, confirmed meniscal tears, and no associated osteoarthritis. The principal finding was that the patients who had a meniscectomy were no better off a year later than those who had a sham operation (insertion of the arthroscope but no meniscectomy). I must say, I was impressed with the methodology, which went so far as to simulate the noise and sensation of a meniscectomy in the sham group, and to match the procedure times, so that patients would not be offered any clues as to which procedure they had. It was also not a surprise to me that the study was done outside the United States, where I believe it would have been extraordinarily difficult to recruit both patients and surgeons to participate.
The other article was an analysis of recent trends in health care spending. The authors pointed out the nearly unprecedented recent decline in the rate of growth of the per capita national health expenditure. They offer up a number of possible reasons, and are appropriately tentative in attributing the slower growth among them, but they make a compelling case that the payment reforms baked into the Affordable Care Act are partly responsible. Whatever the cause for the slow-down in cost trends, they also make it clear that it remains important to reduce national health care costs even more. Here they call for, among other things, reforming payment models to providers to avoid “unnecessary care” and “engaging consumer in making better health care choices” (and, presumably, providing financial incentives to do so).
That last part is where I think the articles connect. The Finnish study cited statistics that identify arthroscopic meniscectomy as the most common orthopedic procedure performed in the United States. If it really is of no benefit for many of the patients currently having it done, then educating patients to avoid it, and no longer paying doctors to do it are exactly the kinds of changes we need to embrace to lower overall health care costs. Pulling that off requires supporting high quality research into what really works to improve patients’ outcomes, as well as giving up on fee-for-service as the dominant payment model, both of which make sense to me.
What do you think?
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.