How a medical student can exacerbate the high cost of health care

Even as a medical student, I’m already complicit in exacerbating the problem of the high cost of health care.

It hit me one day, during my medicine rotation.  We were working up a patient, and I was ordering tests with my resident.  The patient had liver disease and perhaps some ascites.

He came in for another issue, and this wasn’t of primary concern to us, and we really wouldn’t have done much of anything inpatient to treat it.  But this was my first liver disease patient, and I wanted to see what the ultrasound would look like.

I could’ve looked it up, but it’s cooler – and easier to remember – if it’s my own patient’s.  So I suggested, in the med student leading-question fashion, “What would an ultrasound show in this case?”  My resident rationalized my request with the offhand comment “Well, it *is* a teaching hospital.”

And that’s the thing – it *is* a teaching hospital, and I am a medical student.  I learn by seeing and doing.  I didn’t think about the patient getting billed for that ultrasound.  Or that his Medicaid would get billed for it.  And taxpayers and the system would pick up the costs.  Or that the procedure wouldn’t be covered, and the patient wouldn’t be able to afford it, and the hospital would have to eat the costs.

We’re often told that “Before you order a test, think about what you’re going to do with the result.”  But that’s easier said than done.  It’s reflexive that, when you order morning labs, you order labs on everyone, sometimes those that don’t need it.  Sometimes you want to confirm your clinical diagnosis, even though you wouldn’t necessarily change your plan.  (Hey, I’m a beginning 3rd-year medical student … I like affirmation when I finally nail a diagnosis).

If I were a patient paying for my hospital stay out-of-pocket, would I be more vigilant about what tests are being run on me, how many vials of blood were being drawn each morning?  Patients don’t think about that or even know to think about that.  They trust that their doctor is doing what’s best for them.  But “what’s best for them” isn’t always what’s best for the wallet.  The doctor isn’t thinking about the wallet.  It’s not how the physician was trained.

If there were a price listed next to each item you could order in the computer system, I bet it would change behavior.  1 BMP = $15.  1 CBC = $10.  1 PT/INR = $6. 1 set of LFTs = $15.  That’s almost $50 in the average morning lab order, per patient.  I’d think twice about what I’m ordering if I were presented with a bill after my shopping spree in the computer order system cafeteria.

The reason I’m part of the cost problem is largely because I don’t know how much things cost, and I don’t think about it.

So make me think about it.  This is a teaching hospital — I’ll learn.

Suchita Shah is a medical student who blogs at University and State.

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  • http://www.VoiceHIT.com Peter R

    Great article, Suchita! :)

    Way to fight the good fight!

    Hope you’re well,

    pr

  • Zachary M

    I’m a first year medical student myself, and I find myself kind of getting on my peers’ nerves when I ask about cost. Until I get into the clinic on a daily basis and see the effects on a real person who is suffering, many treatments (particularly antibodies) just don’t seem worth the cost considering our long-term problems financing health care.

    On the other hand I think that society is making an investment in your knowledge and skill as a physician. An ultrasound isn’t very expensive… but I suppose it wouldn’t be smart to run that logic past your patient. Hmm.

  • Marc Gorayeb, MD

    Great observation. However, the issue runs deeper than cost. Testing can cause disease. Through complications associated with chasing positive results, which in some cases only amounts to an exercise in satisfying your medical curiosity. Remember this in residency, because the pressure to acquire procedural skills will be immense. It will distort your clinical judgment.

  • C Dahlin

    At our hospital, antibiotic use, and some tests changed significantly when the price antibiotics were put on a different sheet, with the price next to them,
    I suspect this would be true for other tests, too.

  • http://www.occampm.com/blog Michelle W

    My family had a run-in with this aspect of teaching hospitals when, as a toddler, I was in a major car accident. While I thankfully suffered few injuries, my blood work showed something strange. They started intense testing in an attempt to track the problem. It got so that anyone who entered my room with a white coat had me crawling up the walls, and I had to be restrained in order for them to take the blood.

    One night a nurse saw that I was asleep and told my mother that in order not to wake me up she’d only take two small bullets (I think that’s the word, any doctors here could probably correct my terminology if I’m wrong). My mother, having seen the large amounts of blood taken on previous occassions, asked why she was taking so little that night. The nurse explained that since the hospital was a teaching center, standard practice was to take extra blood from patients for educational purposes. The next morning my mother calmly informed my doctor that I would no longer be donating to the teaching hospital: they would only receive the amount of blood they needed for the tests. She and my father both offered to donate blood if it was required, but refused to see me put through that amount of pain again if it was not necessary for my treatment. Sometimes it’s not just about the cost in a monetary sense, but also the nature of how that “extra” test will affect the patient.f

  • Hexanchus

    I agree with the others – great article. Unfortunately, teaching institutions often lose sight of the fact that the priority is supposed to be the patient’s needs, and stories like Michelle’s are all too common.

    That’s why I:
    1. Avoid teaching institutions if at all possible (most especially in July!)
    2. Cross out any general consent language on the forms and add “No tests, treatments or procedures of any kind without my specific prior approval.” before signing it.

  • SteveBMD

    Zachary,

    I know what you mean… I went to med school in the late 90s and was roundly criticized– and even ridiculed– for asking about the cost of tests and procedures. (I learned very quickly not to ask those questions on rounds, but instead wait for 1-on-1 time with my attending!)

    Even today, I’m not given much respect by my peers when I make comments about a 10-fold difference in cost between two equally effective medications. I usually get the refrain of “you’re not paying, and neither is the patient.” That may be true, but someone is!!!

  • http://warmsocks.wordpress.com/ WarmSocks

    Those tests are much more expensive than you’re guessing. Thank you for caring what the cost is. Sure, insurance covers part of it, but I still have to pay 20%, and my 20% adds up to several hundred dollars annually. Looking at my last few bills, here are the real outpatient fees (I’m told that inpatient is more expensive, but thankfully don’t know for sure):

    $20 blood drawing fee (one lab only charges $10)
    $39 BMP
    $43 CMP
    $39 CBC w/ diff
    $44 ESR
    $40 CRP
    $11 SGPT
    $11 SGOT
    $11 Creat
    $11 Albumin
    $83 ANA
    $54 UA w/ micro

    My outpatient ultrasounds have been in the $150-300 price range (after insurance adjustment).

  • anonymous

    Great post! I want to add that some attendings contribute to this problem by insulting the resident or medical student if he or she did not have a lab result available when asked. Granted, the reason was usually because that test did not come up on my radar rather than my making a conscious decision not to order a test because of costs. But once you have been chewed out in front of everyone else, you order everything you can think of to avoid it from happenning again. I think changes need to happen from the top down.

  • Mary J

    I’m a 4th year medical student in the UK, and on a recent ICU rotation, I noticed that all the equipment DID have prices on it. It was amazing how you think about what you’re using and ‘opening in case you need it’ when you’re aware of what it’s costing the system.

  • jsmith

    This has been going on in teaching hospitals forever; the incremental cost importance is zero. Don’t sweat the small stuff.

  • Killroy71

    Don’t sweat the small stuff?? It adds up! Just like the earlier poster, I too am on the hook for 20% of costs until my deductible kicks in at $5,000, so I’d appreciate it if all you docs would pay attention to costs. In the business world, this is called “cost-effectiveness” or cost-benefit ratio. I see so many comments by docs and pts saying they don’t want insurance coming between them, well guess what, that’s an easy fix. Just try going to a doctor and how happy they are to see you when you tell them you don’t have insurance but you can pay cash. You’d be paying attention to costs if every patient asked you, “what does that cost? I’m paying out of pocket. Do I really need that?” You don’t want to have those conversations, and you count on the buffer of insurance to take you off the hook, but then you complain that insurance DOES ask some of those questions. There is no universe in which cost does not matter, because we all pay — taxes, premiums, public/private, any kind of system you want. So, thank you to those docs who expressed here some level of awareness about that fact.

    • http://warmsocks.wordpress.com/ WarmSocks

      You only pay 20% until your deductible kicks in? Lucky you! I pay 100% out of pocket until my deductible has been met. After my deductible has been met, then insurance picks up 80% of the cost and I only have to pay 20%.

      You are absolutely right! It adds up, and gets expensive. I appreciate it when my doctors keep cost in mind.

    • gzuckier

      Yeah, as the previous poster said, that’s not a deductible; you pay all of everything until you reach your deductible. You sound like you’re talking about a cap or some such.

      (Note that, deductible or not, you still get the benefit of your insurance company’s negotiated fees; for instance, my last blood tests, nominally billed at $450, but even though i was paying since I hadn’t hit the deductible, I got to pay the insurance company’s price of $150)

      • Killroy71

        You’re right, I do pay 100% till I hit the part where I pay 80%…see, that’s how confusing insurance is! Some preventive care is covered upfront, but not as many screenings as they’d give me if I let ‘em!

  • Dm2

    Suchita, around here we would just grab a resident and an ultrasound, and have a peek (with the patient’s permission). No orders, no cost to the taxpayers.

    @Hexanchus: So you expect only the less-sophisticated to train the healthcare providers of tomorrow? Nice contribution to society.

    • Hexanchus

      Not at all.

      The problem, as I see it, is that the entire medical industry has run amok. Far too many tests and procedures are conducted that are unnecessary, in that they either don’t provide any additional relevant information or the results have no bearing on any course of treatment. This is even more prevalent in teaching hospitals, as is the documented increase in death rate due to medical error in the month of July – why put up with the hassle or take the chance? It has been proven that more medicine is not necessarily better medicine – in fact, the opposite is often true.

      My personal issue is not financial, as I have pretty good coverage, but the points others have made here regarding the costs incurred by patients are very real for many patients and need to be considered before randomly ordering a bunch of tests.

      With respect to not allowing any tests, treatments or procedures without my specific consent, I simply refuse to be a guinea pig. Before I will consent, I require some basic information:
      1. Why do you want to conduct this test or procedure? What are you looking for and how will this help?
      2. What exactly does the test/procedure involve?
      3. With respect to #1, what are the sensitivity, specificity, and positive and negative predictive values for the test/procedure you are recommending?
      4. What are all the potential risks, complications and side effects of the proposed test/procedure?

      That’s why they call it “Informed Consent”.

      Admittedly, some things like a CBC are pretty mundane, but things like a CAT scan or MRI are not. Any provider that can’t answer those basic questions has absolutely no business recommending the test/procedure.

  • SteveBMD

    jsmith,

    What exactly do you mean by “incremental cost importance”? If you mean that the costs of tests ordered by med students for “teaching purposes” are minimal compared to overall hospitalization costs and other expenditures, you may have a point. However, we’re talking here about physicians in training, and the decisions they make early in their careers will be repeated over and over again in every setting in which they work. That adds up. Fast.

  • gzuckier

    Totally New Idea:
    copays for doctors. I.e., for every charge, not only does the patient pay 10%, but the doctor pays another 10%.

  • C Dahlin

    The costs are also inflated-because hospitals contract for x percent of their rates, they inflate the rates to try to get what they wanted in the first place-but those are the rates given to underinsured patients. And they are the ones most likely to get slammed with the bill! One of my patients had catastrophic insurance only, ans a huge retroperitoneal bleed from anticoagulation for her PE. The insurance did not pay for acute rehab or home nursing for dressing changes.She did not qualify for medicaid because she own(ed) a house,although she had no income. The nickel and dimes charges added up to something huge.
    You can tell your patient by the way, that many hospitals, labs and radiology suites will negotiate prices-for example to pay what the insurances would pay an insured patient, usually if they are paid up front, but it’s often 30% cheaper. They cant’ SAY that up front, because it becomes their “usual and customary”charge.