Part 31: Do Conflicts of Interest Increase Healthcare Costs?

Conflict of interest (either apparent or real) is an important subject not only for ethical reasons but also for business reasons; the appearance of as well as reality of conflict of interest are both important.  Thus, such conflicts are a matter of concern in business and industry, and the healthcare sector is not an exception. Ideally such should be prevented. Nevertheless, when identified, these must be eliminated for the greater good of the populous. 

In many instances, a conflict of interest acts against the mission and negatively affects an organization’s image, intended outcomes, and eventual profit margins. Therefore, organizations and companies should take affirmative proactive actions to prevent conflicts of interest. When instances are identified, the root cause(s) must be identified and promptly eliminated and proactive steps taken to prevent recurrences for the greater good of the organization and the population. 

The scope of this article does not allow addressing areas such as nepotism (giving favors to relatives and close friends), competing interests of individuals or their loyalties to the workplace or the mission, self-dealing, performing side or unauthorized (private) business at the workplace, fiduciary situations (e.g., board of directors), insider trading, or the abuse of position or authority.  

In addition to the conflict of interests, there are racial and ethnicity-based biases that lead to significant healthcare disparities and clinical outcomes. While some protocols are based on older research, other are on speculations and negative bias. Examples includes, treatment of hypertension and diabetes in African American versus the rest of the population, treatment approaches and disparities in mental disorders, such as anxiety and depression, polycystic ovarian syndrome and menopause is women. 

Another area is the excessive cost for consumers on prices of drugs, devises, and procedures. Same drug is sold by pharmacies to consumers and hospital procedures cost several folds higher when paying in cash in comparison to obtaining under insurance.  In this article, focus is on examples of duplicity of interests in healthcare that affecting clinical outcomes.  Let’s focus on specific examples from the healthcare industry, where duplicity of interests negatively affects clinical outcomes.

Conflicts of interests leading to overlooking disease prevention:

A powerful network of healthcare organizations and larger healthcare entities leverage their financial might and bargaining power, using billions of dollars to lobby the government to increase their share of funding and obtain concessions to assure highest business profitability. Consequently, these entities oppose elimination of loopholes; this is one of the key reasons for lobbying. In addition, lobbying focuses on the relaxation of regulations for the industry with less oversight, enabling higher profits with little benefit to the public.

The power of lobbying, using billions in funds, allows manipulation of entrenched legislators from both parties. These funds (which are normal operating expenses for companies) are eventually passed through to the consumers and also add to healthcare costs, making healthcare less efficient and less beneficial to consumers. In return, legislators overlook closing loopholes, oversight, and minimize the priority given to disease prevention. Constituents should consider voting out such lawmakers through the ballot.

Examples of how conflicts of interest or lack of understanding hindering disease prevention:

Osteoporotic fractures: 

Most non-traumatic, osteoporosis-associated fractures are preventable by straightforward advice and actions. These include, implementing a combination of lifestyle changes and targeted physical and occupational activities leading to improvements of balance, reflexes, muscular strength, and prevention of falls; improving eyesight, hearing, and nutrition; and using appropriate medications, including calcium and vitamin D. 

Moreover, some osteoporosis-related tests carried out by radiology (also by other) facilities and laboratories tests are done poorly without quality control. Thus, the resulting test results and interpretations are inaccurate and misleading; yet there is zero oversight on such. For example, standardized and regular training are provided by the international society for clinical densitometry (ISCD) on correct producers and properly interpreting bone mineral density (DXA) testing (minimizing serious pitfalls). Despite these, many facilities continue to carry out inaccurate DXA procedures; wrong interpretations of these by inexperienced physicians make these worse and harming patients. In these situations, relying on history and clinical findings are far better than carrying out worthless DXA testing.

For patients who present with an osteoporotic fracture [e.g., colles’ fracture (fracture of the wrist), vertebral fracture or a hip fracture], one in five (i.e., 20% of those with fractures) will come back with another fracture, within a year. This is primarily because the mentioned process has not been implemented by physicians, especially at the accident and emergency departments or by orthopedic surgeons. Having one osteoporotic fracture indicates fragility of the rest of the skeleton. Thus, it is not surprising such a person is at high risk for recurrent fractures. Patients coming in with a fractures are captured audience to provide the needful to prevent future fractures.  Yet, this is happening in less than 30% occasions. 

Importance of fracture prevention:

Following hip fractures, approximately 25% of patients die in the first year and less than half those who survive a hip fracture regain their previous level of function, especially among those with comorbidities.  This negative vicious cycle becomes exponentially worse when a patient sustains the second fracture, especially fracture of the remaining intact hip.

Because the death rate after a second hip fracture is extremely high, prevention of secondary fractures is a priority. In the absence of physicians discussing preventative approaches, a patient presenting with an osteoporotic fracture has a high probability of returning with another fracture, which markedly increases the risk of death. This is despite osteoporotic fractures being preventable.

It is noteworthy that preventing a fracture, on average, costs less than 5% of the cost of fixing a fracture. In addition, as many as 30% of women and 55% of men with vertebral crush fractures have underlying “secondary” causes leading to bone loss and thus, osteoporosis.   

Moreover, Identification and elimination or treating these secondary causes (e.g., vitamin D deficiency, hyperparathyroidism, excessive urinary calcium losses; thyroid abnormalities, bone marrow abnormalities, myeloma, etc.) by itself, markedly improve the bone density and bone strength. Moreover, such treatment might lead not only to increasing bone density but also preventing of future fractures, which relieve much burden on people and cost a fraction. 

Non-treatment of secondary causes increase the risk of fractures:

Identifying and treating the underlying secondary cause (i.e., a disease that enhances bone loss and weakens bones) of fracture is an essential part of providing care for patients with osteoporotic fractures. Thus, a thorough medical history, physical examination, and appropriate laboratory investigations, such as those to eliminate underlying causes of bone loss, are important. Not employing these measures can harm patients, which can be considered negligent and unethical medical care. Inaction or failing to provide appropriate advice on the part of the physician can lead to the patient sustaining another fracture that could have been prevented.

Diagnosing and eliminating secondary causes such as vitamin D deficiency, hyperpara-thyroidism, excessive urinary calcium loss, thyroid abnormalities, myeloma, could significantly  reduce future fractures. This would also lead to improve balance and reduction of falls and enriches bone density and strength. Therefore, such approaches reduce the risk of fractures and the socioeconomic burden on people, especially the elderly, and decrease cost of healthcare management. 

Although seems trivial, “non-providing fracture preventative measures” to fracture patients, significantly increases the chances of them coming back to the emergency room or orthopedic departments with yet another fracture. This generally happen within one to three years and are preventable. Therefore, fractures prevention must be addressed by all physicians, including PCPs/GPs, geriatricians, etc., as an essential component in medical management of the elderly, especially when they sustain a fracture.  

Lack of priority given for fractures prevention: 

Despite the evidence, less than 30% of persons with fractures admitted to hospitals and emergency rooms receive a referral or treatment plan for preventing future fractures.  

Most recurrent osteoporosis-associated fractures are preventable if patients receive the right advice and treatment at the time of encounter with medical professionals for their first fracture. This is a major failure in care and a lost opportunity for fracture prevention. Consequently, each year, more than 1.4 million osteoporosis-associated fractures occur in the United States alone. The author believes that more than half of these fractures are preventable.

Effective fall-prevention advice and assistance are not provided to most of the elderly, even during physician encounters. One in five significant falls in the elderly leads to a fracture [https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html]. However,  A systematic approach to fall prevention is essential care during patient encounters with persons who are at high risk for falls, but sufficient efforts are not directed to the elderly to prevent falls, injuries, and fractures.

When diseases are prevented, there is less need for medicine, procedures, and expensive hospitalizations. It also reduces the need for expanding, including mergers and acquisitions of hospitals, and improves the health of the population, their productivity and happiness. Thus, it a no-brainer that preventative approaches to illnesses significantly reduce healthcare costs. Next article will extend this theme, using vitamin D as an example.  

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Professor Sunil J. Wimalawansa, MD, PhD, MBA, DSc, is a physician-scientist, educator, social entrepreneur, and process consultant. He is a philanthropist with experience in long-term strategic planning, and cost-effective investment and interventions globally for preventing non-communicable diseases [recent charitable work]. The author has no conflicts of interest and received no funding for this work.