In the discussion of cutting health care costs, it’s often pointed out that the doctor’s pen is the most expensive piece of technology.
Hospitalist Bob Wachter talks about the medical profession’s zeal to “do everything” as a major driver of health spending. So, how can we stem this tide?
Doctors are programmed to advocate passionately for the patient in front of them, with little regard for the macroeconomic impact of their decisions. Dr. Wachter argues that by involving more of them in larger integrated health systems, physicians are part of a more communal setting. That’s important, since, “it involves creating structures that make the docs confident that any money they save stays in their immediate organizational circle, reallocated by reasonable people to other patients who might benefit more.”
But, as it stands, most doctors practice in solo, or small group, settings, making it “more likely the docs will fight such reallocation and tar the effort as ‘heartless rationing’ by ‘faceless bureaucrats’.”
I’ve argued that transitioning the majority of the American health delivery system into integrated models is one the biggest challenges before us. But, as Dr. Wachter reminds us, it’s not as easy as waving a wand and magically propagating the Mayo model nationwide. Indeed, these established systems have been around for 50 years or more.
If we can somehow find a way to successfully do so, it will immeasurably help.
Related posts:
- Why rationing is a dirty word, and can we ever limit care in America?
- Should health care come with a warranty?
- Why it’s difficult to put doctors on a salary
- Health care is not a right: The fight continues in Colorado
- How to convince doctors to accept health reform
- Doctors, nurses, HIPAA and Britney Spears
- Poll: How should we pay doctors, and why we need to change the financial incentives
{ 16 comments }
patient comes in with minimal head trauma, does not meet standard criteria for head CT. insists on one because he doesn’t want to “die like natasha richardson.” threatens to sue if we don’t do one and something is missed. hospital admin constantly quacking about keeping press-ganeys up. patient unable to be convinced otherwise.
physician with no financial disincentive to order CT. patient with no financial disincentive to have CT ordered. CT done and negative. patient goes home happy. physician picks up next chart.
If you want to establish integrated systems, begin by recruiting primary care docs and pay them 50% more than they would make on average in small practices. They’ll preferentially refer to the specialists in the system, and other specialists will be pushed to join.
Grand Junction, Coloradao, is often proposed as an example of a system that works and holds down costs. It is characterized by a much greater than average number of primary care MDs. But even they are having trouble recruiting them, and think this will be a major problem in the near future.
There is also a legal issue here. All of us live in fear of being sued because we didn’t order some expensive test, even when we suspect it will be normal. A lot of the expensive tests ordered are for CYA purposes.
R Watkins is right; the answer is primary care, primary care, primary care. Specialists order tests because it is just what they do, financial motive or not. Neurologists order cervical mris in 80 year old patients even though they know it will show djd. Pulmonologists order pfts just to find out that their obvious copd’er has copd. Cardiologists, fuggetaboutit. They order carotids on everyone. Why?
patient comes in with calf pain and is diagnosed with DVT. physician orders CT in patient with no symptoms for PE. patient gets high does of radiation, physician cares more about money. patient has big bill to pay. doctor has money for his car payment.
I want a doctor who is just concerned about ME, and not have medical services “reallocated by reasonable people to other patients who might benefit more.”
Isn’t that rationing?
What Dr. Grumpy said. And it’s not all about the doctors.
There seems to be an increase – over the last few years – especially in Pediatrics – of people/family members coming into the hospital/ED and making a scene/copping an attitude/causing a stink/threatening to sue – in order to get what they want – never mind that they often don’t really know what they want.
It oftentimes interferes with the care of the patient. If a staff member (nurse/doctor/whatever) is afraid to walk into a room for fear of getting their head chewed off, they’re going to avoid the room.
A good portion of the time, those exhibiting the worst behavior are on public assistance and do not want to pay for any of the expensive/unnecessary things they want (and I’m sorry, if you really want to talk about reform, this is an expectation now passing from generation to generation that the government has bred).
The doctor/staff caves (be it with ordering labs/tests or transferring someone somewhere they don’t need to go) just to keep the peace/get through the day and try to take care of the patient.
In effect, bad behavior is rewarded.
This is another example that if you say something enough and long enough it must be true. It might have been true a long time ago. Primary care physician rarely see a financial benefit from ordering more tests. Stark laws made it almost impossible for doctors to own outside entities and use them. HMOs, PPOs and other insurance insist that for their paitents, certain labs and radiology and hospitals be used. If the clinic has a lab or Xray the fee paid by the HMO covers that service–no matter how often they use it (capitation). They also must approve all expensive tests like MRIs and CTs. Medicaid also must preapprove these tests. As noted above the patient often insists soemtimes even with threats that tests be done. There is also the tort protection aspect which is why tort reform would help. The doctor gets no more money but avoids the time consuming and emotion draining suits, even if frivilous. CVS is offering flu shots now. So patients can choose to get their shot too early (protection may not last season) and even if they don’t need it. In the meantime doctor’s offices won’t get it until later and often are not supplied enough for their sicker population.
DVT:
Unless you were seeing a radiologist for diagnosis and treatment of your DVT, the physician who ordered the CT didn’t make one red cent by doing so. This is a classic example of CYA medicine, and it is an enormous burden on the system.
“the physician who ordered the CT didn’t make one red cent by doing so.”
The physician is part owner in a multi-specialty group.
would you have sued if you wound up with an undiagnosed PE? be honest.
“would you have sued if you wound up with an undiagnosed PE? be honest.”
I have been misdiagnosed 5 times, two of which lead to a permament disability. I didn’t sue. The one that showed compassion is still on my medical team despite his mistake. Perhaps I should sue the others.
If I had an undiagnosed PE and died, I don’t think I would sue.
Of course, you point above is that patients drive unnecessary cost. (Is piece of mind for a scared individual really unnecessary as you imply?) I didn’t ask for the CT and the doctor is responsible for the unnecessary CT.
Not. your. job. And it never will be.
Your job is to offer optimal care, for an INDIVIDUAL patient’s INDIVIDUAL circumstances, always.
How to limit care? Well, just establish an internet database with treatment protocols and evidenced based best practices of course. Then clerks can input patients symptoms and in return receive an individualized treatment plan. Then only tests “approved” by big brother will get ordered.
Patients won’t be able to stomp their feet and demand “more be done”, they can’t argue with a computer after all. Docs won’t get sued, we would just be following protocol after all. Cover-your-a** orders won’t be needed. Docs would only be sued if they deviate from e-standard of care and deviation (i.e. thought) wouldn’t be allowed.
Since inappropriate or redundant tests won’t be allowed, risk and guilt-free limited care will result.
“The physician is part owner in a multi-specialty group.”
Thus representing less than 10% of practicing American physicians? Give it up. Greedy doctors are not the reason for overtesting. A culture of CYA and “do everything possible” has emerged from a combination of the most lawsuit-happy system in the world and aggressive marketing of technology. Changing that culture will only happen if either the malpractice system changes or the government imposes strict limits on what it will pay for.
SarahW-
“Not. your. job. And it never will be.
Your job is to offer optimal care, for an INDIVIDUAL patient’s INDIVIDUAL circumstances, always.”
What about that fourth principle of ethics that we so often ignore – social justice? Healthcare is a limited resource whether we like it or not. We focus so much on autonomy that we do so at the expense of social justice. We allow some people to have “everything” which may leave nothing for others. While I advocate for my patients to the best of my ability, I do think that doctors AND patients need to be more aware of the limited resources we have and the need for allocation to acheive social justice.
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