Health costs need to be addressed by doctors, patients, and lawyers

It’s no secret that our health system encourages doctors to order too many tests.  Compounded with the widespread belief that more tests equates to better medicine, the reasons why health costs are spiraling out of control aren’t a secret.

In a perspective piece from the New England Journal of Medicine, physician Sean Palfrey notes our dire situation:

Recent advances in scientific knowledge and technology have resulted in the development of a vast array of new tests, new pharmacologic agents, and new diagnostic and therapeutic procedures. These are so accessible to us in the United States that few of us can resist using them at every opportunity. By being impatient, by mistrusting our hard-earned clinical skills and knowledge, and by giving in to the pressures and opportunities to test too much and treat too aggressively, we are bankrupting our health care system.

To fix this, every player in the health care arena needs to take responsibility, and make changes. That means doctors, patients and lawyers.

For doctors, Dr. Palfrey urges that, “we as clinicians must change our practice patterns, but first the medical community, through standard-of-practice guidelines, must give us permission (or better yet, encourage us) to practice in a less costly way, so we don’t feel we are expected and incentivized to order expensive tests or treatments.”

For patients, “we need to teach our patients that more medicine is not better medicine, that it is poor health care for doctors to order too many tests or too many interventions, and that costly efforts do not equal better health care.”

And, finally, for lawyers, “the legal system needs to be more restrained about pursuing lawsuits when a difficult diagnosis is missed or a treatment fails, to diminish the pressure on health care providers to practice expensive, defensive medicine at every turn.”

There will be, of course, opposition from each constituent. There are physicians, for instance, who oppose practicing by guidelines, calling it “cookbook medicine.” Some patients will always ask for the best, most expensive test or treatment, and put their own individual health status above that of the general public. And there will always be lawyers who dispute the assertion that medical malpractice litigation is a contributor for health costs.

Until each party takes responsibility and propose solutions that may not be in their selfish interest, but instead, benefits the our health system as a whole, it’s unlikely that we can change the trajectory of our soaring health costs.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Matt

    The only thing that will change the cost of healthcare is revamping the payment model. Anything else is basically trying to empty the ocean with a teaspoon.

  • http://fertilityfile.com IVF-MD

    I can tell you from extensive experience and evidence that when patients themselves bear the cost of treatment and testing, the paradigm immediately shifts from “I want every test and treatment possible” to “Hmmm, is this really necessary?”.

    • http://paynehertz.blogspot.com Payne Hertz

      If patients have the knowledge to make an informed decision about testing, what do they need doctors for?

      • Apurva Bhatt

        Or to ask it another way, if their doctor tells them that there is little value to additional testing, then why do they so often still insist on it?

        • http://paynehertz.blogspot.com Payne Hertz

          Because doctors can be wrong and the price the patient pays for them being so is sometimes death. It is reasonable if not scientific to want to cover all the bases and not base things on assumptions.

          • Apurva Bhatt

            But that’s the crux of the dilema. You can never be sure, and there’s always more tests that can be run, or re-run. However, there’s an asymtotic relationship between the number of (and cost of) tests and their diagnostic value – beond a certain level, additinal testing is unlikely to provide greater diagnostic value.

            Is it reasonable to expect someone else (usually an insurer, but often the state, i.e. the tax payers) to pay for each indivitual’s insatiable curiosity or anxiety about our health? If not, who decides how health care resources are used, and based on what standard?

      • http://fertilityfile.com IVF-MD

        From a philosophical viewpoint, it’s absolutely correct. If you make the correct call on your own, you don’t need a doctor.

        From a realistic viewpoint, doctors will still be needed to perform surgery and procedures.

        From a legalistic viewpoint, doctors control the monopoly on the distribution of medications (whether you feel that it’s ethical or not). So if a patient correctly identifies a medication or product that he needs, he still needs to beg the doctor’s permission to get it. One real-life example that I encountered was when a optometrist diagnosed my friend’s vision as requiring routine refractive correction and diagnosing the precise diopters of correction in each eye. However, it took great fighting on her part to get a legal prescription that she could submit to a contact lens distributor to get her product. The doctor tried to demand that she purchase the identical product only from him (at nearly double the price).

        • http://paynehertz.blogspot.com Payne Hertz

          The reason I ask this question is your solution puts the onus on patients, who often lack the knowledge to distinguish whether a particular test is necessary or not and also have no authority whatsoever when it comes to ordering tests. A patient may ask, beg or demand a test, but only a doctor can order that test So who is ultimately responsible?

          The state gives doctors this monopoly on testing on the assumption they will use this authority wisely based on their specialized knowledge and ethical principles, and not for their own self interest.

          Yet when they abuse this authority for their own self-interest (on the often misguided belief that it is necessary to keep patients happy or to cover their rears from the mere threat of malpractice), you propose punishing the patient with the cost. How does this make sense?

          Patients also face the stigma of being labeled “noncompliant” for refusing tests and procedures for whatever reason, and that can also result in doctors who are overcautious about malpractice—the very ones who order excessive and unnecessary tests–to refuse to see such patients. It’s an obvious Catch 22.

          Finally, penalizing patients not only results in their refusing unnecessary tests, but necessary ones as well. If you’re going to bomb patients, surgical strikes work better than carpet bombing.

          • http://fertilityfile.com IVF-MD

            PH, you bring up many different points (ultimate responsibility, doctor’s monopoly access to testing, cost of testing), all of which provide excellent food for mutual enlightenment.

            My take is a doctor is just a human being. Sure we have the distinction of having participated in the care of 1000′s of patients more than a plumber or accountant have, but this doesn’t make our medical knowledge base omniscient. So much of medicine is an art, a gray area. So my role is to explain the pros and cons of each testing or treatment option and let the intelligent patient help decide. OK, sure, there is the occasional patient who has no wish to participate and just wants to be told what to do, so those we will treat in a more authoritarian manner.

            As for the payment comment, how is having a patient accept responsibility for the costs of his testing a “punishment”? Because you are not buying me dinner or paying my rent, is my having to pay for my own dinner or pay my rent an act of you punishing me?

          • http://paynehertz.blogspot.com Payne Hertz

            In reply to IVF-MD and Apurva Bhatt:

            As for the payment comment, how is having a patient accept responsibility for the costs of his testing a “punishment”?

            There are only two kinds of incentives: carrots and sticks. That this is a stick is obvious. It is a punishment in the same way sending your kids to bed without supper is a punishment, except in this case, the kids are the ones paying for dinner, and the price they are paying is inflated by monopoly rents.

            Patients are only human too and can’t be reasonably expected to always second-guess their doctors, particularly as tests are often ordered for the wrong reasons, and refused for the wrong reasons as well. Many patients rightfully fear challenging their doctors.

            When patients do not get answers to their medical problems, they understandably wish to continue testing until they do. There is no hard and fast answer anyone can give as to when testing should cease in a given individual, let alone in the general population, so such decisions tend to be rather arbitrary.

            One way to deal with testing costs it is to make testing cost less by eliminating testing monopolies and also eliminate the necessity of expensive doctor shopping by allowing patients to order any test they like, so long as they are willing to pay for it and accept the risks involved.

      • http://www.doconomics.com Christopher Gregory

        Payne, the reason we need doctors is that they are, will always be, an integral part of the healthcare equation, i.e., knowledgeable, skilled physicians + the adequately, properly informed physician’s patient = best possible outcome. Patients don’t make informed decisions on their own.

    • HJ

      When I got sick, we were having difficulties making ends meet. I could not have paid for the tens thousands of dollars in medical care that my doctors recommended.

      None of the testing was necessary because it didn’t save my life or reveal a diagnosis. Perhaps being responsible for the cost would have saved me much pain and suffering. I do wish I could avoid the doctors and get my prescriptions without the hassle.

      • http://fertilityfile.com IVF-MD

        Worse than that. Sometimes, shotgun testing turns up a statistically significant (but clinically insignificant) outlier value. This then gets pursued with even more testing and in some extreme circumstances leads to getting major SURGERY! Over-testing is not only financially harmful. Sometimes it can be outright physically harmful.

        There was once a time in this country where you COULD get medications without begging a doctor’s blessing. I agree that you should have the choice.

        • HJ

          At what point is something over-testing? After the first test comes back negative? The second? When there are still common diseases on the table? When the patient runs out of money?

          My experience has made it very clear that vague symptoms aren’t worth investigating.

    • http://nomidazolam.blogspot.com J-M

      What if you tell the Dr. and the rest of the enormous “team” that you do NOT WANT a certain treatment or test? In my experience you are then labeled “difficult” or simply treated without regard to you wishes. Even telling the Dr. that you can’t afford the extras will get you nowhere. After my experience I live in fear of medical treatment because of cost AND lack of autonomy.

      • pj

        Then you need to seek care/help elsewhere.

        Honestly, I am amazed by folks that claim they are “captive” to a certain Doc or hospital system.

        The USA is a BIG place, J-M, and you are FREE to talk to their competitor.

  • paul

    here’s how to correctly use this tactic to save money (setting aside the argument of what is more important- saving money or giving true appropriate, individualized care to each patient):

    1) rigorously identify findings in the history, exam or otherwise that predict the pathology of interest that can be found by the diagnostic test of interest by studying a large number of patients with the appropriate presentation, all of whom get the test done

    2) prospectively validate use of the set of findings to order the diagnostic test in another large number of these patients, identify the miss rate for the diagnoses of concern

    3) either accept as a society the miss rate that is found or be forced to accept it by our ivory tower organizations or the government

    4) withold payment for tests ordered without the criteria found in the above studies

    5) eliminate the possibility of lawsuits for that percentage of patients who falls thru the cracks but for whom we as a society already decided it is okay for them to fall thru the cracks. and i don’t mean you “win” the lawsuit. you don’t get sued at all.

    if any of the above steps are missing, i would be very skeptical about any success to be had with regard to cost control.

  • paul

    oh, i forgot-

    6) don’t send a press-ganey to patients who don’t get the study ordered because they didn’t meet criteria!

    :)

  • Anonymous

    Ironic, considering the previous article on placing a central line in a DNR patient. The consensus of the comments seemed to be yes, of course, treat the patient. WTH???

    This is why I not only have a Living Will, at a certain point I will tell my family: if you think I’m dying, call no one until you’re certain I’m dead. This approach has worked well for two of my family members, BTW. Cost-effective as well.

  • JPB

    What do you do when you have no symptoms and your physician wants to do lots and lots of tests? Until individuals feel free to question their doctors, we will not have any progress in controlling costs!

  • http://emergency-room-nurse.blogspot.com girlvet

    The doctors who don’t want to practice medicine under standard of care or evidence based guidelines that have scientific proof, should be penalized economically. They are not practicing in the best interests of their patients.

    As far as what patients expect and demanding unneccesary tests, there is a simple solution to that, doctors need to say one simple word: NO. What a concept.

    • http://www.BocaConciergeDoc.com Steven Reznick MD

      When doctors say ” NO” to many of our empowered patients, they say ” Good Bye” and go to the next practitioner until they find one that does it their way. If they were held financially responsible for a good part of the test they might listen to reason and scientific data related evidence.

      • Greg

        More importantly, doctors are increasingly being held to patient approval in order to get paid – so that “No” results in negative “performance reviews” from patients and thus a salary cut. It’s a terrible idea, as, like girlvet says, that “no” can save both lives and money. But as Americans demand a “customer is always right” model, they tighten the noose around their own necks.

        Remember the foreclosure crisis? When people got mortgages that would have made a 1990′s banker ROTLF? That’s what happens when people who should be told no, aren’t.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      If those scientific guidelines include cost considerations, then their application may be in the best interest of a statistically aggregated “society”, but not necessarily in the best interest of A particular patient.
      So should doctors be financially penalized for practicing patient-centered medicine instead of population-centered medicine?

  • http://www.hopestreetgroup.org/index.jspa Joy Twesigye

    I agree that every player needs to have skin in the game. But I think the way this is framed continues the same adversarial responses and leads to a stalemate. What if the patient took on the personal responsibility to quit smoking, exercise, eat less fried chicken and check/record blood sugars? The providers could focus on individualizing care plans for complex patients–not everyone may get an MRI but they would have more time to evaluate whether one was necessary or not. The lawyers could join the fraud waste and abuse team at CMS and penalize the people who are billing the government for colonoscopies they did not do instead of raising the blood pressure of the ER doc. In this scheme everyone changes but the movement is forward instead of at each other and each person’s actions still has the ability to improve health outcomes and reduce cost. We lay out specifics on how each of these parties could help reinvent the way we conceive of and deliver care at http://www.hopestreetgroup.org/docs/DOC-2367

  • http://www.doconomics.com Christopher Gregory

    Dr. Pho, I agree with everything you’ve written here. We suffer from the maladies of over-worried (a big thank you to pharma), over-diagnosed and over-treated. I had the privilege of reading Dr Richard Young’s book “American Health Scare” that I hope will be published soon. He dissects the waste running rampant through the “government-industrial-medical coalition”. Too much – way too much too often. Americans are a medically pampered brat population who want what they want when they want it. And we wonder why we are going to be bankrupted by health care costs while the orgies of excess go right on.

  • http://www.talktoyourunconscious.wordpress.com BobBapaso

    Nobody is going to change their habits because it’s the right thing to do. People will change if it will save them money because they are paying for their care from there own personal Health Care Savings Account with they personally own.

    Let’s encourage everyone to start a Health Care Savings Account.

  • http://www.ama-assn.org American Medical Association

    As our nation works to address health care costs, the ultimate goal is better value for our health care spending. A new series of publications by the AMA, available at http://www.ama-assn.org/go/healthcarecosts, highlights specific topics and actions to help address costs and improve benefits in our health care system. As Dr. Pho notes, there are many areas of our health system to consider when looking at health care costs – including medical liability reform, health IT, a focus on prevention and wellness, and comparative effectiveness research. The AMA web site includes presentations and white papers on these and other topics as part of our strategies for reducing health care costs.

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