Who's to blame for overutilization?

Patients with inflated expectations demanding medical perfection, or doctors who overprescribe tests?

Merrill Goozner (predictably) takes the anti-physician stance. I think it’s a bit of both.

Comments

Stalwart Hospitalist
“But more significantly, why am I, Patient, being asked to make these decisions at all? How many years of medical school do I have under my belt?”
I often wonder this when I have patients tell me that they “need” an MRI, a CT scan, a specialty referral, an extra day in the hospital, a Z-pak, disability, etc.
I would think these types of decisions (as opposed to financing structures) would be even MORE applicable to all my years of medical training.
Anonymous
How does a patient “demand” anything from a professional? If your professional judgment dictates they don’t get it, you don’t prescribe it.
Anonymous
Agree that it is a combination both. But one needs to keep in mind that patients don’t come up with “I need the test” decision by themselves. They often react to what they hear or read in the media.
So what you have is:
1) TV-doctors and journalists describing how “everyone needs this test” even if it isn’t true.
2) radiology labs posting ads and send flyers to public offering “packages” of “three necessary tests” and using scare tactic to convince public that these tests are necessary. Some of the readers may go to this lab, but others take the flyer to their doctor and ask “why didn’t I get this test”.
3) common view that “earlier is always better”, “everything can be cured if caught early”. There are very few opposing views anywhere in the media.
4) patients who, after listening or reading about these tests, demand them from their doctors
5) doctors who after listining to these demand from some patients assume that every patient wants more testing. Since patients who think otherwise are often not that vocal and tend to trust their doctors, you do the tests based on assumptions of what patients want.
6) some doctors who order tests because of “utilization” demand from their superiors or other monetary gain. We saw doctors mention it in this or other blogs. IMHO – this is theft or insurance fraud depending on who is paying.
7) doctors who order tests for defensive reasons
So it is indeed a little of everything.
Anonymous
“How does a patient “demand” anything from a professional? If your professional judgment dictates they don’t get it, you don’t prescribe it.”
Because for most of us refusing the patients’ demands involves far more time explaining this risks and benefits of tests than to simply order the test. Also, there is the small but non-zero chance that patients will have a bad outcome, the patient frustrated that they get the test they “needed” is more likely to sue.
I’m not defending this, but this is the reality facing most physicians every day. I prefer seeing patients with high deductible plans or paying cash, not because they’re paying me for the test (they don’t) but because they don’t insist on every test and a complete workup of every possible etiology of their symptom.
The moral hazard of having third party payment for tests is real and the financial impact is enormous.
Anonymous
“Because for most of us refusing the patients’ demands involves far more time explaining this risks and benefits of tests than to simply order the test. “
In other words, you do it because you’ve chosen to enter into a reimbursement model which does not reward you for your professional skills, but rather for your ability to keep the system ginning money.
“The moral hazard of having third party payment for tests is real and the financial impact is enormous.”
Kudos to you for recognizing it. Now you just have to get your colleagues to wean themselves from it, rather than casting aspersions on everyone else in the system.
Anonymous
1:02, please tell me you are playing the Devil’s advocate and aren’t actually believing that doctors prefer this “reimbursement model.”
The reimbursement “model” exists because of those who pay for it–the employees and their employers and the taxpayers who pay their FICA taxes and who vote.
If you are a doctor in most places, you make whatever peace you can with the “model”, comfortable, but increasingly not, or ugly or desperate. In many places, if you don’t play the insurance game, you might as well close your doors and let go your staff–patients will not pay cash.
Weaning will have to be by the patients; they are the ones who must wean themselves off relying on third-party payment with no skin of their own in the exchange.
Anonymous
No one makes a physician sign up to be paid that way. It’s a contract, and you choose to enter into it.
There are 40 million uninsured – do they never need healthcare? there’s your cash market right there. Not to mention the wealthy, who would likely pay extra for better service.
You guys have been insulated from the actual business so long that you’ve forgotten how to market your skills and how to add value to the service you’re delivering.
The public pays nearly every other profession directly – so why would it be so hard for them to adjust to paying you?

Who’s to blame for overutilization?

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