Health care cost control requires saying no to patients

Let’s face it, the best way to cut health costs is to say “no.”

That means denying unnecessary tests that most patients in the United States are accustomed to having.

The New York Times‘ David Leonhardt has the best take on this issue that I’ve read. He acknowledges the difficulty of telling the American public “no,” and cites examples ranging from the breast cancer screening controversy to the managed care backlash in the 1990′s:

This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment. Consider that a recent study found that 15,000 people were projected to die eventually from the radiation they received from CT scans given in just a single year — and that there was “significant overuse” of such scans.

The economic arguments against overtesting simply won’t resonate with patients. Despite the dire forecasts of bankruptcy and Medicare insolvency, “the try-anything crowd occupies the moral high ground … Compared with an anecdote about a cancer patient looking for hope, the economic arguments are soulless.”

He proposes capitalizing on the uniquely American traits of free choice and more control instead. Give patients and doctors the necessary effectiveness data to make their own decisions on whether to undergo a test. Some studies even suggest that patients would err on the side of not testing once all the risks and benefits are known.

As for doctors, the malpractice system shouldn’t punish them for a shared decision that holds back testing, yet results in a poor outcome. Instead of advocating for malpractice caps, I agree with shielding doctors who follow clinical guidelines from liability.

Leonhardt says it will be very difficult to say “no” to the American “yes “culture. But if we can empower patients by providing the information to make their own informed decisions, perhaps we may not need to.

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  • paul

    yep. and the two important questions to be asked are
    1) who makes the decision to say no?
    2) who is legally responsible for the consequences of saying no?

    in an ideal world, the answer to both questions is the patient. they make the decision whether or not to spend their own money on a given test, treatment, etc. and are responsible for the consequences of choosing to purchase or not purchase the service.

    the other extreme of course is to have a central agency like the government decide what will or will not be paid for with tax dollars, and to hold itself accountable to some degree for the consequences (or, i suppose, grant itself sovereign immunity). if done right this could be palatable (many people may not agree with this statement).

    where we probably should be headed is some hybrid of the two, in order to contain costs effectively. instead, we appear to be heading towards a system where the government decides when to say no, and the physician is legally responsible for the consequences. well, that ought to work out real well, since everyone will be happy with that arrangement. all the important people, anyway. right?

  • BD

    Who benefits from more tests and procedures?

    1. The patient. But if the patient doesn’t benefit, and may be harmed, this should be explained to the patient. I agree physicians should not be held liable for fully informed patients who refuse then have second thoughts.

    So who else benefits?:

    2. Pharmaceutical and medical device companies

    3. Physicians (not necessarily the physician ordering the test or procedure)

    4. Other medical staff required to perform the test or procedure

    5. Hospitals who allot space and time in their facilities for performing the test or procedure

    There are more. Follow the money, especially to see how this demanding, aggressive, “do everything” group of patients was created gradually over the last 30 years or so.

    • Butch Phelps

      I agree. I believe patients should be informed and allowed to make the decisions. If the patient chooses not to have a test, then have them sign a release form and get it notarized for proof. Take the pressure off the doctor, as he/she is only a guide in the process. If the patient is in control and they choose the more expensive test, then the patient can only say they caused the increase. On the back in, a lot of other healthcare entities would lose money, but the process would be less costly for all.

  • Eli

    We live in a culture of new and improved and have been convinced that having more is the ultimate goal. Those profiting from excessive testing will continue to convince us that is what we need. We are convinced with fear of death while real harms are hidden from sight.

    While I am all for shared decision making, I don’t have a degree in medicine. No matter how many hours I spend on Google, I need the trusted advice of a phycisian. I have been exposed to 3 CTs and not once were the risks explained to me. One of these CT’s were done defensively and if the circumstances had not been urgent and I had time to think, I would have declined. Experiences like this have eroded my trust in doctors and now Dr. Google is my main source of information and that is where I put my trust. While many doctors here will say I am foolishly risking my health, I was already risking my health in our current health care system.

  • family practitioner

    As a family physician, I spend a good portion of my day advising people not to have tests, ie your neck hurts but an xray will just show arthritis, so what’s the point? That is just one example.

    Some patients respond to this, others don’t; a lot want to see a speciailist; who am I to say no to that? What am I, a gatekeeper or something? However, once they see the specialist, that pandora’s box is open (xrays, mris, emgs, etc).

    Patients need to realize, and respect, the notion, that frequently, in medicine, LESS IS MORE.

  • David

    This is a hollow argument. The culture of testing to the ‘nth degree will always be there when the responsibility for ones’ health rests in the health care system. A shift back to individuals being responsible for their health needs to occur along side change in every conceivable societal domain to create a healthy environment. Unless our country gets healthier in its approach (metaphysically) and lifestyle choices (physically) we will bankrupt ourselves pursuing “healthcare,” which is a ruse anyway!

  • Diora

    Given that the doctors often order unnecessary tests without our asking for it, I think the post is a bit one-sided. It only addresses the issue of patients’ requesting tests, not the issue of doctors ordering the tests without our knowledge (e.g. specific items on a blood test – are we supposed to know what each ordered item means?) or consent or doing non-recommended tests during checkups.

    1. The study done by NEJM a couple of years ago, showed that over half of annual physicals include non-recommended tests – EKGs, urinalysis, etc. These tests usually happen without patients’ specifically asking for it. At least in my, completely anecdotal experience if you come for a checkup, the nurse does the EKG before you ever see a doctor. I’d say no – I have no special risks – but I don’t want to waste time arguing with the nurse; it’s easier to comply. Less stressful. Then, at the end of the visit the doctor gives you a slip paper with a bunch of things marked on it to take it to the lab. Sure, I could ask the doctor – which tests are ordered and why, but then I’d be holding the doctor up and possibly creating a conflict situation which is stressful. Even in cases where we know the tests non-recommended, we patients just find it easier to comply.

    2. Last year, I specifically mentioned to my doctor that I’d like to have pap smears less often than once a year given both the recommendations and my extremely-low-risk status. The doctor said, we prefer to do it every year, but if you prefer otherwise, fine. This was last year. But this year, she decided to do it, and as I had another thing on my mind (I had some cramping I wanted to discuss), I didn’t feel like creating a fuss. To my surprise, when I got the insurance statement there was an HPV test ordered as well. I sure as hell didn’t ask for it, nor was it ever mentioned to me. This is of course completely anecdotal, but I’d be very surprised if this is not common.

    3. Even recommended screening tests have both benefits and risks, but in many cases the risks aren’t ever discussed. In many cases – see discussion some time ago, women are blackmailed into having the tests because the tests are made pre-conditions for birth control.

    4. A couple of times I got a flyer in the mail from some radiology lab that advertised “specials” on 3 completely non-recommended cardiac imaging tests. Not only the fllyer used scare tactic by painting how serious the conditions are, it was full of deliberately misleading information. I.e. it said the tests were recommended for people over 50. Now, I know they aren’t. How many lay people do you think know that? Of course, you may say who cares, people who go to this lab pay out of their own pocket. But not only these tests have risks, they can have false positives and false positives will be handled by insurance and cost a lot more. Plus, take a guess, how many insured people took this flyer to their doctor and asked “doctor, why didn’t you order this”. You don’t want people to demand tests – do something about this type of advertising. It’s your collegues who are doing it.

    5. TV-doctors do a whole lot of promotion of unnecessary tests in their programs. These doctors are presented not as your average MD, but as experts. Being on TV has a clout. People think – oh, this guy was invited on TV, he must be great. I used to watch one of these programs, but sometimes the endless test promotion made me want to throw something at my TV, so I stopped watching all together. But these programs are popular.

  • Wellescent Health Blog

    Ultimately, unless there is some support for doctors who chose to say no, patients who have developed that “try anything” approach will simply find a doctor willing to do whatever that patient wants. Support from government and the insurance industry in defining a resource of worthwhile tests for particular scenarios would allow a baseline of comparison to at least be set.

    This baseline could be used to inform patients such that when they go from doctor to doctor, all the doctors could point to this reference as the reason they are not recommending a test.

  • family practitioner

    I think Diora’s comments are excellent; and show how many different players are part of this problem, including the physicians.

    I try to be the doctor that tells people what they need (and don’t need) but it ain’t easy.

    These radiology screening programs are a disgrace (carotid sono, echocardiogram, abd sono, bone density, pvrs all for $150). The doctors that legitamize this stuff should be ashamed of themselves.

  • andymc

    “This baseline could be used to inform patients such that when they go from doctor to doctor, all the doctors could point to this reference as the reason they are not recommending a test”

    Yes, and I try to use baseline like the CDC, ACS or USPTF guidelines when a patient asked about getting a test..”do you know what the American Cancer Society recommends about getting that test?. This is what I try to follow..” I find this helpful for all but the most unreasonable patients..

  • Dana

    I’ll give my personal experience with a cancer diagnosis as the reason why we should NOT dismiss tests – I found a swollen lymph node 7 weeks postpartum. I called my OB the first thing the following morning and was told he was “not concerned” and to come back the next week to see if there had been any changes.

    I called my Family Practitioner the following day who was a little more concerned, ordered a breast ultrasound, a CBC and a referral to an ENT for a biopsy.

    The radiologist who reviewed the ultrasound said the node appeared to have “Benign Adenopathy”, the CBC was completely normal except for slightly elevanted CRP levels with could be anything, it took 3 pathologists (including 2 specialty pathologists) to confirm Nodular Sclerosing Hodgkins Lymphoma. Bone marrow biopsy and PET/CT showed it was Stage II.

    Other than a small (1.4 cm) swollen left supraclavicular node, nothing indicated I could possibly have cancer, but I did.

    If we stop running tests in all cases, people like me will fall through the cracks and the diagnosis will be much later and the prognosis poorer. How would you explain that to a new mother with 2 children 2 and younger?

    The reason most physicians run test these days (in my experience) is to cover their backsides against a litigious society that will find a good ambulance chaser and sue.

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