Physicians and Containing Health Care Costs

Kenny Lin MD is a family physician who is an associate editor for the journal American Family Physician and blogs as the Common Sense Family Doctor. This was first posted on his blog on April 15th and gives commentary on the physician’s lack of training in containing costs in health care and the potential conflicts of interest physicians face in this arena.

The cost-conscious physician: an oxymoron?

Several years ago, when my wife directed the third-year Family Medicine clinical clerkship at a highly ranked medical school, she developed a popular workshop on the cost of health care that presented students with scenarios of patients who were either uninsured or underinsured and challenged them to provide cost-conscious health care by selecting medications and tests that were clinically appropriate and financially affordable. Many students remarked that it was the only time during their two years of clinical rotations when they were required to consider costs in decision-making.

Now that the U.S. health reform bill is law, and over 95 percent of Americans (as opposed to today’s 84 percent) are expected to have health insurance by 2014, many physicians may be tempted to think that they can ignore the costs associated with prevention, diagnosis, and management of patients’ health conditions and just focus on doing what’s “right” for the patient, since somebody else is footing the bill. But contrary to popular opinion, that “somebody else” isn’t an insurance company or the government; ultimately, it’s the patient, in the form of higher insurance premiums (or taxes) to pay for an ever-expanding range of tests or treatments of questionable or zero benefit.

In response to Dr. Howard Brody’s challenge to the medical profession to identify lists of unnecessary tests and treatments, physicians have suggested antibiotics for colds, coronary calcium scans, PSA and thyroid tests in well patients, drugs for high blood pressure that are more expensive and offer fewer benefits than older drugs, MRIs and spinal fusions for low back pain. If it’s so easy to come up with a list, then why is it so hard to eliminate the waste? According to a recent Newsweek article, the problem is that many of the items on the list are physicians’ financial “bread and butter.” “We doctors are extremely good at rationalizing,” says Brody in the article. “Somehow we manage to figure out how the very best care just happens to be the care that brings us the most money.” Other concerns voiced by physicians are that patients have come to expect (if not demand) much of the aforementioned unnecessary care because it’s been going on for so long.

But if health care reform is to have any hope of slowing the extraordinary growth in the cost of health care in the U.S., doctors can’t keep looking to patients, hospitals, pharmaceutical and medical device companies, and insurers for solutions. In an editorial in the New England Journal of Medicine, Dr. Molly Cooke argues convincingly that cost-consciousness must be systematically incorporated into medical and continuing education:

First, we should be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care.

“Value” isn’t about saving money, but means getting the maximum health benefit for our enormous investments in health care. This wake-up call needs to be delivered and reinforced to students, residents, and health professionals at every level starting today.

Also see    Difficult Choices  and Financial Armageddon

3 Responses to Physicians and Containing Health Care Costs

  1. Health care in the US is somewhat unique in that the purchaser of the product and end user are not the same. I feel that it is really not possible to design a system that can effectively control costs if the user is not fully informed and involved.

    Here are some illustrative cases.

    1) A patient falls from a height, landing on the forefoot and pulling the achilles tendon. He presents to the office with edema and ecchymosis around the achilles tendon. Examination reveals a negative Thompson test (achilles function intact) so that a total tear is ruled out. A partial tear is likely. I started practice in 1983. At that time, we would have then treated the patient based on a working diagnosis of a probable partial tear and applied a short leg walking cast. By the mid 1990s, an MRI would be ordered as the risk of not doing so was high especially when practicing in a state without tort reform (ie. Washington). By the mid 2000s, the cost of diagnostic musculoskeletal ultrasound had plummeted and was available for office use.

    Musculoskeletal ultrasound, in my experience, has allowed me to see achilles ruptures better than MRI at about 1/10 the price. I will make my presentation to the patient. Diagnostic ultrasound at $150 or MRI at $1500. The patient responds, “Doc, which one is covered by my insurance?” He does not respond by asking “which one is better.” A patient with a HSA (Health Savings Account) or a high deductible policy which is more common where I practice in San Antonio will ask, “which is better and what is the cost?”

    2) Plantar fasciitis, a major cause of heel pain. This can be treated via conservative means in over 95% of cases. A small percentage of plantar fasciitis can become recalcitrant due to degeneration of the fascia. The underlying cause is now termed “plantar fasciosis.” Many such cases are treated via surgery, EPF or endoscopic plantar fascial release. That procedure has an abysmal success rate. One of the leading worker’s comp attorneys in Tacoma once told me that he has never seen a worker undergo EPF and return to the original occupation. Newer technologies have supplanted EPF to include ESWT (extracorporeal shockwave therapy) and the Topaz (coblation) procedure with minimal disability, morbidity, low complication rates and relatively little time loss.

    Health care costs not only include the dollars that an employer pays to a health insurer but the lost time and productivity to an employee. It is thus in the interest of employers to favor treatments that are non-invasive or minimally invasive. But is that what the “establishment” really wants?

    I used to teach podiatric residents as an instructor podiatric surgery; 3 different programs. I recall a situation where it appeared that podiatry residents were enocuraged to book as many surgeries as possible. It was my duty as a surgical instructor to teach ethics as well as technique and informed the residents about their responsibility to offer non-surgical options. The administration of that program castigated me and soon after, forced me to resign.

    What happens when a locale becomes heavily controlled by a few “big players” that want to maintain the high cost paradigm of overtesting and overuse of surgical procedures. The decent, honest practitioners need to leave.

  2. If you are referring to the recent health care reform bill, I am not convinced that the issues you bring up are going to be much different than the ones we now face. If lots of us retire it will be more likely due to loss of income from working hard rather than the issues you present.

  3. Do you have any thoughts about why doctors have been silent as their profession has been socialized? Other than the AMA which jumped on the bandwagon early, doctors haven’t been as outraged as I thought they would be even though I hear 25% of them will simply retire to avoid the onslaught of paperwork, new patients, and diminished control of the care they give patients.

    Thanks for your comments.

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