Doctors are not the only ones to blame for unnecessary tests

One of the points of contention in health care reform is whether it will do enough to control costs.

Forget about the Congressional Budget Office’s optimistic outlook, as it discounts the Medicare “doc fix,” which, when factored in, will erase any supposed deficit reduction.

Reform doesn’t do very much to change the underlying structure of our health system, which continues to pay more for quantity of medical services, rather than shift the focus to value and quality.

Sharon Begley, writing in Newsweek, offers some sensible suggestions on what we can do control costs. Better incorporating the best clinical evidence into their medical decisions would help. She cites the continued, and possibly unnecessary, use of back surgery, knee surgery, vertebroplasties, and angioplasties, despite mounting evidence that they’re being overused.

One reason is the continued resistance of many doctors to change their practice habits. Another is a payment system that encourages more testing.

But a significant influence is patients themselves:

Consumers, too, are a powerful force for unnecessary medical care. Parents insist the ER do a CT scan on a child who bumped her head; runny-nose patients won’t leave their internist without a prescription for antibiotics. “In a busy practice, it’s sometimes easier to write the prescription than to talk the mom out of it” . . . And the heart patient who doesn’t believe that pills could possibly be as effective as surgery? “Angioplasties, stents, and bypass have attained ‘entitlement’ status.”

It’s not easy to repeal the “more testing means better medicine” mentality, especially when it’s so entrenched in the American psyche.

But we can start by not demonizing just doctors, but acknowledging that every medical medical stakeholder, including patients, needs to take some responsibility.

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  • R Watkins

    “Forget about the Congressional Budget Office’s optimistic outlook, as it discounts the Medicare “doc fix,” which, when factored in, will erase any supposed deficit reduction.”

    Whether or not the doc fix occurs is completely independent of the health care reform bill. There was no reason for the CBO to include it in the estimate of the bill’s cost.

  • Anonymous

    While I wholeheartedly agree that patient’s must take greater responsibility, I am not optimistic that this goal will be attained any time soon. As long as the current financial structure, where patients believe they are paying too much yet are almost fully shielded from the true cost of services, perseveres, I believe patients will want to “get what they paid for” in a very tangible sense. It is not that patients are unable to grasp the the main points of this post, but rather that what patients want for everybody else is different than what they want for themselves.

  • paul

    three necessary things to control costs in health care.

    1. change the system to one where the patient directly purchases health care services, using their own money, to the greatest extent that that is possible. (obviously catastrophically expensive things like lengthy icu stays would be impossible, and a certain segment of our population simply can’t pay for most or any of their health care)

    2. minimize situations where physicians are financially incentivized to perform numerous expensive procedures regardless of dubious clinical benefit

    3. kill the 800 pound gorilla lurking in every exam room, ready to pounce and fight tirelessly to get everyone compensated for their “pain-n’-suffering”

  • jsmith

    The only way HC inflation will get under control in this country (or any country) is hard rationing. It can be done by done by global budgeting (as they use to do in Canada and the UK) or by queue (not enough doctors or MRIs, etc). The idea the we docs and the rest of the HC establishment and the pts are able to do this on our own is sheer fantasy.
    Is Americanready for this reality? Not now, maybe never. Then pony up to the cashier’s window, America.

  • lazza11

    “Forget about the Congressional Budget Office’s optimistic outlook, as it discounts the Medicare “doc fix,” which, when factored in, will erase any supposed deficit reduction.”

    I also must object to the lead-in to this story. If health care reform had not passed, then we would still be looking at adding the doc fix to the deficit PLUS the trillion dollars that HCR saves us over 20 years! We are clearly fiscally better off having passed this bill (not even to mention the 32 million Americans getting health insurance)

    Apart from that the bill is chock full of investigational programs into various payment reforms and comparative effectiveness of different treatments so that we KNOW what the best practices are – this should give *some* ammunition to fight against entrenched practice “habits” and patient preferences (though we saw with the mammogram recommendations and continued vaccine outcry that erroneous beliefs do not die easily even in the face of scientific evidence!)

    Alone of course these investigational programs might not be enough if we lack the political and institutional will to implement them! To counter this the bill also creates an independent Medicare commission to reform payments – what Medicare pays for and how it pays for it. It will be headed by healthcare experts appointed by the president and congress; the recommendations cannot be filibustered and become law without a vote from congress. This is a HUGE step toward payment reform – taking away the responsibility for action from a congress paralyzed by the filibuster rule, short term political considerations, and interest group influence, and giving it to experts in the field to make the tough decisions that will be needed to avoid bankrupting the country! It may be the greatest delegation of congressional responsibility since the creation of the federal reserve, and could just stand a chance of preventing health care outlays from bankrupting the US government! (we have clearly seen that congress over 25 years has been unable to do it alone)

    Also – it should be noted that the possible savings from the studies and the medicare commission implementing them (and then hopefully private insurers taking up the same reforms) are mostly ABSENT from the CBO scoring of 1.2 trillion dollars saved. This is valid because the CBO has no way of estimating what the total savings of payment system reforms might be, but they could dwarf the 1.2 trillion dollar figure if lawmakers, hospital administrators, insurers and (perhaps most vitally) physicians commit themselves to improving outcomes and lowering costs for all Americans. It will still be an uphill battle and will need support from all sides.

    Nonetheless Democrats should be lauded for having the resolve and foresight to pass such far reaching, important and CONSERVATIVE legislation (very similar to Mitt Romneys plan in MA), a plan built on private insurers and not government takeover of ANY part of the healthcare system, and against a wild eyed campaign of misinformation from Republicans more interested in regaining control of congress by obstructionist tactics than having a hand in solving Americas fiscal healthcare crisis. After all in 8 years in power all the ONLY thing Republicans did for health costs was add the HUGE unfunded medicare part D entitlement to the deficit (Projected Medicare part D net expenditures from 2009 through 2018 are estimated to be $727.3 billion)

    Will the bill do enough? Perhaps not – but it does make a very solid start and moves us toward a system which is more cost sensitive… If Republicans would engage seriously in debate on the merits instead of stirring up McCarthy era paranoia and conspiracy theory fantasies then we would have a much better chance as a country going forward at fixing the problems that beset us on all sides.

  • paul

    i’ll add
    4. anyone who chooses to be dependent on the government for picking up the tab on their health care needs to understand that there are limits to the care that will be offered. these limits need to be studied rigorously and clearly and openly defined, including the reasons behind what is and isn’t offered (i.e. procedure A isn’t offered because the benefit is too marginal to justify the cost, with both the benefit and cost displayed for all to see). the provider that is operating within these predefined limits should not be subjected to reduced pay because of dissatisfied “customers” or to lawsuits because of bad outcomes that are a direct consequence of certain services being withheld.

    in other words, open rationing. rationing will not be necessary for every spending decision that is made directly by the patient using their own money, so the more health care that can be done that way, the more rationing can be avoided. when your health care is being paid for with someone else’s money, the current “all you can eat trough” model is not sustainable.

  • Steven Wynn

    Nice try Iazza.

    Congress is NOT going to let the cuts go through (at least for a prolonged period of time) and so you have to calculate that into health care costs. It’s just more political gaming.

    “HCR saves us over 20 years!” Says who? The CBO? Sure they’re “non partisan” but it’s still headed by a democrat and have a democrat majority in their committee. Besides, just because the CBO says something it must be true? Somebody’s been sipping on the Koolaid I see.

    “After all in 8 years in power all the ONLY thing Republicans did for health costs was add the HUGE unfunded medicare part D entitlement”

    Your right here, but who first proposed the drug prescription benefit program? The DEMOCRATS! Under which president? CLINTON! They tried to pass it but they failed (since the GOP controlled the House at the time). Can’t just blame one party for the unfunded mandate. Both parties rallied for that.

  • Evinx

    I nominate Paul to be in charge of reforming health care.

    Put Paul in charge, dump Congress, Obama, Sebellius, Ezra, et al.

  • rezmed09

    How can we expect to reduce any costs if the only actions our legislators and presidents can do increase costs? We cannot even reduce drug costs, we cannot even bargain with drug companies, we cannot reduce direct advertising of new drugs. No, the only action our executive and legislative branches have taken is to increase the give away that is Medicare part D.

    We’re just a people who cain’t say no….

  • Matt

    “3. kill the 800 pound gorilla lurking in every exam room, ready to pounce and fight tirelessly to get everyone compensated for their “pain-n’-suffering””

    You guys have done that in a number of states. Hasn’t changed the frequency with which you order tests.

    • J

      Because regardless of what caps are placed on medical malpractice awards, the malpractice rates themselves still skyrocket with even the suggestion of a lawsuit – independent of whether or not it actually gets investigated/goes to trial.

      • Matt

        So your insurers just raise rates at the suggestion of a lawsuit?

  • Kent

    Hello To all you good people that may read this, and answer.
    I would like first, to address Kevin; Kevin. you provided very good information on the subject of the emotional status of many patients.
    To the point: Baby Boomers seem to always be the ones blamed for diminishing Social Security funds, as well as diminishing Medicare funds? Citizens born before WWII are on Social Security, as well. Many ‘X,’ ‘Y’,’ and whatever the other generations are called (I have lost track of all pet names of the generations after Baby Boomers) Are on S.S. Disability. So why blame the BBs. Can anyone answer the question?
    Sincerely, Kent NcCain

  • Jake

    I sprained my ankle on a Friday evening.
    It was a really bad sprain and by Sat am was very swollen and painful and obviously a severe problem.
    My primary care physician has office hours Mon thru Thurs plus Fri morning. I did want to go to the local hospital emergency room, but at a nearby shopping center there is an “EmergiCare” facility that was open. So I went there.
    The physician examined me, had an x-ray done (which he said indicated there was no broken bone), prescribed a brace and OTC painkiller, and sent me on my way.
    By the beginning of the following week, my ankle was really hurting so I called my physician for an appointment. She saw me promptly on Monday, and said I would need an Xray to rule out a broken bone. I told her I already had one, and gave her all the relevant info (where, when, etc.). She said they would try to get a copy of the Xray. Later, her office called to tell me that they could not get the Xray, and that in any case my physician would require that the Xray be read by her specified Radiologist, so I would have to get another Xray. I then went to another location for another Xray. The results were the same as the first-no broken bone.
    My physician prescribed a lot of physical therapy, and now (4 months later) I seem to be completely recovered.
    Whose fault was it that I had to repeat the Xray? I don’t know, but it certainly appears to have been unnecessary.

  • Med Humanities

    Having had a lower back & hip x-ray, my PCP reported results to me including, a spinal stenosis. Radiologist suggested an MRI. I turned that down, since this was the equivalent of an incidentaloma which doesn’t bother me, and I wouldn’t have anything done about it anyhow. How can we get more patients to have the same reaction, that’s the question.