How doctors can reduce unnecessary tests and treatments

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.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • http://www.consentcare.com Martin Young

    Kenneth, you are absolutely right.

    But every now and then patients slip through who would have benefitted from exceptional testing.

    I saw yesterday a patient I had seen three years ago, then with headaches and nothing to show clinically for her symptoms. This time she had a complete left opthalmoplegia due to a large sphenoid sinus mucocoele.

    I know it’s rare. I know I’m not going to get sued for missing a rare diagnosis based on a very quick but thorough single clinical consultation. But I really wish I had got a CT scan. And this is the patient I will remember – not the many negative scans I order that put my patients’ and my anxiety to rest.

  • R Watkins

    I saw two patients today for follow-up on chronic prostatitis, both treated with the same antibiotic (first line treatment as recommended in Sanford – any other treatment would have been “sub-standard”).

    One said his co-pay for the script was zero dollars and zero cents; the other said his co-pay for the same script was $648.

    And you’re telling it it’s my fault that costs are out of control, Dr. Cooke?

  • Not Savvy

    I protect myself from unnecessary medical care by doing the research, coming up with my own diagnosis, treating myself when possible and only seeing a doctor when absolutely necessary. I will then decline treatment if the doctor and my research have different opinions, trusting my research.

    I learned the hard way that trusting a doctor whose financial interest is more important than my health is foolish.

  • rezmed09

    Here we go again. The doctors, who make too much, spend too much, and don’t spend time with their patients, don’t answer their calls….. Yes, the doctors must lead the charge to reduce tests and procedures?

    I don’t see how all the medical education and CME is going to stand up to the over testing and over treatments that are done in all university training hospitals. Also, there is no way providers can under-test with the amount of patient anger out there – let alone the risk of litigation. In many practice settings, there is very little downside to ordering more tests and procedures. Patients feel like they got “everything done” and docs have objective and quantitative data to justify discharge from ED or hospital etc. This is what an influential portion of our patients want.
    You want the idealistic docs to disappoint patients and possibly increase their litigation risks by relying more on their clinical exam and judgment to reduce medical spending? That is not going to happen in this environment.

  • Jenga

    Now it’s up to us. Well we might have bought in if they included us from the start or at mininmum threw us a bone such as safeharbor for using comparative effectiveness guidelines. Save em, HAH, I know right where to send my patients when they come with torches and pitchforks when they can’t get their MRI.

  • Tom

    So… You’re citing Newsweek. This would be the bankrupt magazine famous for its lack of depth. Sure you can’t find a better source to indicate the unrelenting greed of doctors?

  • jsmith

    If this country has hard rationing, then HC inflation will decrease. If this country does not have hard rationing, then HC inflation will not decrease. Dr. Lin is wasting his breath.

  • hawk

    Hmmm

    I work in emergency medicine. There is no way I could reduce my testing or treatments, in fact, in light of recent issues I have had I am now working on bolstering and ordering more..

    1st case – was reported to medical board because I sent a nosebleed home. first came in on a friday, with bleeding that was cauterized and packed, with good control. on monday am saw the same pt again because had new bleeding. again repacked with good control, and was dc home for his follow up ent appt. that same day in 2 hours. Per the medical board, I should have gotten ENT to see the pt in the er on the second visit, or admitted the pt for ent review. As far as I know this is not standard of care anywhere, and is in no way anybody else in our group practices, but now I do this, all the time every time, even if it means I have to transfer the patient via ambulance to a different hospital.

    So who cares how much it costs, I have been told that it is the standard of care now. I

    second case – medical board got involved when I saw a patient with a supposed hip fracture. the patient has been seen earlier in the day in our er, had no complaints of hip pain, only lower leg pain. was sent to a nursing home that did not have a bed available, so was returned to the er on my shift to wait for a bed. had no new complaints of pain, so did not have any new testing ordered. three days later comes in with compaints of hip pain,a nd now the lawyer who he hired is stating we missed something, and the board agrees, despite two providers seeing him, documented normal hip exam. we did not do xrays so something was missed. From now on, all patient get complete films, even if they have no complaints of pain. ankle pain, you get xrayed to the hip and pelvis, wrist pain, elbow shoulder will now be included. so much for joint above and below.

    Again, I really dont care about the cost and radiation, if I am going to get in trouble for not doing something, then I will definitely do it, no matter how ridiculous or costly, the next time.

  • max

    Wow you mean all those psa tests are unnecessary in “well” patients? No more screening eh? Just order them when the patient gets his prostate cancer. Ah. Makes sense to me. And so the rationing begins. And its so funny but I have never seen a dime of any mri, xray, or lab test I have ever ordered. How do I get my money?

  • Tom

    W,
    Suppose you go to google and type in “Abdominal bruit”. An ultrasound for evaluation sounds appropriate to me.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Every unnecessary medical test, treatment, medication, consultation, ER visit, hospitalization is someone else’s income. This fine post is arguing for comparative effectiveness research, which the USPSTF mammography debacle showed us all what a tough slog this will be. To paraphrase an aphorism from a U.S. Supreme Court justice, an unnecessary medical test is like pornography – hard to define, but I know it when I see it.

  • joe

    Two points:
    1: Newsweek is a joke of a magazine.
    2: Until someone with real power talks about REAL rationing this is all little more than urinating on a three alarm fire. It doesn’t take a genuis to figure out how europe has controlled costs….they ration care. No dialysis for 85 year olds. No CABG’s for the same. No weeks and weeks in the ICU while a previously uninvolved family wants “everything done” to compensate for their own guilt, or they will call an attorney. Society in europe has made the decision and it is no longer in the doctor’s hands. In addition this excludes some of the the “failure to diagnosis” and “should of done extra test Y” suits, because society has mad the decision for the doc.
    But honestly no dem or rep politician has the balls to actually tell the hard truth to the american people. This truth is blatantly obvious to those of us in the trenches. For example the case of medicare D, that SHOULD be able to as one entity to go up against pharma for the lowest cost drugs possible like the VA. It all comes out of one pocket after all. But no, pharma money through lobbyists at congress derails this idea, get’s what it wants, and is paid back one thousand fold with present screwed up legislation that worsens our ballooning deficit. Good job congress you screwed up again.
    By all means now Dr Lin and Cooke, keep “addressing” that three alarm fire with a tinkle.

  • W

    Well, I just paid $223 (my share of the $600+ bill submitted to the insurance) for an abdominal ultrasound who purpose was never explained to me — I was just at the doctor for a routine physical and feel quite well — and when I received the results (by mail) from the doc, learned “no etiology was found for the left side abdominal bruit.” Period. Huh? No follow-up, no invitation to call for an explanation, zero, zip, nada.

    No pitchforks or flaming torches were involved. Not sure the test proved anything except that I don’t ask enough questions. Then again, previous experience with “patient relations”/risk managers proved that asking questions can be a bad thing too, so it seems to me we’re screwed either way — doctors and patients alike.

    • anonymous

      A negative ultrasound does not fully evaluate an abdominal bruit. This may require an MRI with contrast to look for renal artery stenosis.

      (No, I’m not joking; I did find this in one patient. But I’ll never know whether the vascular surgeon decided to stent it because an insurance change made me “out of network” for him. Next we can argue whether a stent is cost effective or not.)

  • David

    This article stresses the reality that doctors in general do not think about costs when providing care to their patients. The author is correct in asserting that with regard to who pays, “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.”

    I would go further – ultimately it is not only the patient but also the doctor (both taxpayers) who pays, as physicians tend to be in the higher income brackets, and I predict that they will be taxed at higher rates in the future to pay for ObamaCare.

    I fault the author for ignoring the elephant in the room – plaintiffs’ lawyers and malpractice suits. As any practicing physician knows, this drives many of the “unnecessary” tests, because even though the number needed to treat, or test/screen, whatever, may be high, if that one person who may have benefited from the fifty tests you could have ordered finds a hungry attorney, you’re going to court.

  • JPB

    One way to cut back on unneccessary tests is to stop the “fishing expedition” that happens every year (sometimes more often) when a patient is basically ordered in for a well check. The doctor says, “Just to be sure.”

    I have no problem with testing when someone comes in with a problem or is having symtoms but this aspect of “defensive medicine” is costing us a lot of money!

  • Matt

    “I fault the author for ignoring the elephant in the room – plaintiffs’ lawyers and malpractice suits. ”

    You’d think that. But in states where the “reform” physicians want got passed, the amount of testing never decreased, nor did costs. So perhaps we need to be looking at some other factors.