Who’s responsible for bending the health care cost curve?

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don’t provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU).  The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is – will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won’t likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor’s income. Some on the list of Choosing Wisely, however, will.

Take a look at the recommendations by the American Gastroenterological Association specifically around the need for repeat colonoscopy after a normal one.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

Yet, if a doctor does fewer colonoscopies, which is the right thing to do, that also means his income will decrease. In the fee for service reimbursement system, doing fewer procedures means fewer things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece “Do Patients Want More Care or Less”? 

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”… [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.

Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one “just to be safe?” Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn’t necessary, how an individual’s personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn’t talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won’t be the result of our professional organizations rolling out an educational component, or the media highlighting the “waste” in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the “father” of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,”

“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”

“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”

In the end, it will be doctors who can bend the cost curve.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    no routine ekg’s no annual physicals, very nice. There really won’t be a primary care shortage you can basically write off 70% of primary care as not needed. All this lost income, with no help from insurance companies to offset that. 

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    Consumer-directed healthcare, using HSA’s and all that, has been shown to bend the cost curve. People choose very wisely when it’s their own money.

    Of course, since it leaves money, power, and choice in the hands of the individual, and not government, the current administration does anything it can to kill them off.

  • James deMaine

    Thanks for the very thoughtful post.  There is a giant “leaky bucket” of health care dollars that are going to procedure oriented specialists, hospitals, pharmaceutical companies, device manufacturers, technology duplication and competition (every hospital “needs to compete”), administrators (many making more than a million dollars), insurance companies, etc., etc.  I admire you and the groups that are attempting a rational approach to evidence based medicine, yet I fear the lobbying from special interest groups will undermine progress.  Every health care dollar currently being spent (or waster) is “benefiting” someone.  For more please see http://www.endoflifeblog.com/2012/04/health-care-costs-leaky-bucket.html

  • http://twitter.com/Hootsbudy John Ballard

    I realized as I read this that medical professionals are slowly but surely evaluating the frequency of testing and the efficacy of treatment protocols in a serious way. That is a positive, probably long overdue development. But before risking tossing out the baby with the bath, taking a wider look at the big picture. Over at The Health Care Blog a post with the title “You Get What You Pay For” advanced the argument that Yes, we pay a lot, but we also get a few more years and good outcomes in return. 

    Before I could stop myself, I reeled out this snarky comment – 
    When I saw the post title here are a few items that came to mind that we pay for.§  TV ads — some of the most expensive air time for some of the most costly productions in the ad industry.§  Mammoth executive bonuses and golden parachutes for both health care administrators and insurance companies§  Facilities with manicured landscaping, marble floors, lived plants, flat-screen TVs in every room, and concierge food service§  Elaborate accounting arrangements by which large so-called “not for profit” health care systems, often augmented by equally large, embedded insurance companies (BSBS comes to mind) launder bills mostly for the benefit of very profitable clinics, specialty practices and device manufacturers.§  ”Free scooters” advertised for Medicare beneficiaries. Sometimes comes with a free recipe book or lighted magnifier “just for making the call!”§  Catered meals and other treats for hungry office staffs, compliments of your favorite drug or other supplies sales representative.§  And speaking of sales, don’t forget the sales bonuses for high performers. The only people in America with no limit to how much they might earn are not in medicine or other specialties, but in sales. (Investment bankers are in the running, of course, but they are in fact limited by how much capital and/or credit they have. Enterprising sales people have only transportation, cosmetics and a few other expenses.§  Don’t let’s leave out some red meat for the tort reform crowd — legal and accounting services, and a grey area often called “defensive medicine.”With the exception of a dedicated group of community volunteers who provide a few ancillary goods and services, every dime of all that has but two sources:1.) Medical bills 
    2.) Government grants for teaching hospitals and research by NIH. (taxes)
    What am I missing?
    Yes, of course. I almost forgot — MEDICAL CARE!
    After reading this excellent post by Dr. Liu, it seems the main professionals are on the right track. But unless the third-party NON-providers and policy-makers (local, state and national political types I’m looking at you) are still doing the same old costly crap and it’s way past time to take a look at some of the excessive costs that have encrusted the healing arts over the last few decades. Two of my pet peeves are direct to consumer advertising and non-profits (tax-exempt) that are for all practical purposes operational smoke screens for very profitable enterprises making tons of money treating health care as a commodity. And I’m not talking about physicians. 

  • sFord48

     “If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no?”
    I have refused and MRI for back pain.  I have also refused x-rays and medications.  No mammograms either.  I feel a physical exam is a waste of time but my insurance will pay for one, so it’s cheaper than an office visit to refill my meds.

    I have a high deductible plan.  I have skipped medical care because I didn’t have the money.  I go to the internet and only go to the doctor if my research indicates a treatment plan I am willing to pay for.  I am not going to waste $100 just to be sure.

    • http://twitter.com/davisliumd davisliumd

       Agree that as long as patients understand the risk of not getting treatment (no need for antibiotics or MRI for otherwise typical back pain) and do not feel like the care they are receiving is someone “inferior” then that is what we all want.

      However, if patients need to skipped medical care because they can’t afford it, that needs to be addressed. The internet is a tool and certainly can help shape decision making, but should not alone be used as medical advice depending on the situation. For simple things, it can be helpful. For more complex things, medical judgement is important. As some of my patients understand, sometimes you do need to pay $100 because the risk of not investigating further so far outweighs the benefit of skipping needed care.

      Choosing wisely is trying to illustrate what is not concerned needed care based on medical research.

      • sFord48

        You seem to think that the cost of a visit to the doctor stops at $100.  If you can’t afford that medication or that surgery or that expensive lab test, what’s the point of a visit to the doctor.

        • http://twitter.com/davisliumd davisliumd

          I never said that the cost of the visit stops at the doctor. The question is whether patients choose to be unaware or not. For example, if a patient is losing a lot of weight for no reason, the potential possibilities include new onset of diabetes, hyperthyroidism, or cancer. Two of the three are treatable rather inexpensively and the third, not so.

          Will a patient be able to determine which of the three they have? The challenge for patients is do they understand the “choice” they are making if they skip care because they may “assume”, (often times wrongly) that they understand what the right thing to do is. It isn’t possible to fully understand the risks or benefits because they aren’t aware of them if no one tells them. The internet can assist, but alone can’t completely eliminate medical expertise.

          In your response, you have already “assumed” that the medication or lab test is expensive. In my example, a blood sugar test is often done in the office by a RN (no more payment needed and could eliminate the diagnosis of diabetes), blood work is likely ordered (payment depends on insurance coverage, but since are common and NOT exotic should not exceed the office copay), and excellent medications for diabetes cost $10 for 100 day supply for patients without insurance.

          Of course, dietary changes and exercise (eating less and moving more) to improve the condition are absolutely free.

          A recent piece in the Wall Street Journal suggests that at this time, patients typically do make poor health care consumers, hence why doctors must help lead the change. http://blogs.wsj.com/health/2012/04/12/patients-make-poor-health-care-consumers-says-quest-diagnostics-cmo/

          • sFord48

            If you read my original comment, I said if my research indicates an expensive path, I make the decision to pursue medical care dependent on my ability to afford care.  I once had a potentially life threatening problem with an expensive treatment.  I chose to forgo a visit to the doctor because I will not bankrupt my family.

            I have a high deductible health plan…I pay for the cost of the visit, the labs, the x-rays, the MRI.  Isn’t that what doctors want, for me to make market based decisions?  Isn’t that what we are discussing, how great having patients be responsible for the cost so they don’t ask for all those unnecessary tests?  Every discussion on controlling costs contains the virtues of having patients be financially responsible for their care.  Don’t have I the power to determine the path of my medical care?
            I find you comment typical of doctors, making the assumption that diet and exercise is something I need explained in the doctor”s office.  Really?  You think I am willing to diagnose and treat myself and don’t understand the principles of diet and exercise and their role in common lifestyle diseases? 

          • http://twitter.com/davisliumd davisliumd

            I don’t believe you read my comments correctly either.

            I understand what you said – ” if my research indicates a treatment plan I am willing to pay for.” – the question is how certain are we that a patient’s research is the right one? This is not meant to be patronizing. Would it not be better for doctors to help guide patients as well? For example, plenty of people research their own financial investments – that isn’t a problem.  Some are better than others and that is fine for choice.

            The question I am asking is whether patients really want the freedom and responsibility to choose from the bewildering number of choices in medical care or wish to have someone help them (like a doctor). The point of the article is that if there is overwhelming medical evidence that certain treatments or interventions are NOT worthwhile do we expect patients to bring it up (if doctors still continue past behaviors and habits) or should doctors step up and guide them this way?

            My belief is that doctors must step up and lead the way.

            Doctors don’t want patients to market based decisions (if I mistaken,
            please show me articles that indicate that). Insurers and employers want
            the costs of healthcare to slow and that is one touted “solution”.

            Patients should always have the power to determine their medical care and of course can disagree and continue unhealthy habits if they choose to (smoking for example). The point is they should not skip care simply because they feel it isn’t worth it, when at times, something can be done to improve health.

            In terms of the comments about dietary changes and exercise, I never said anything about it needing to be explained in a doctor’s office. Everyone knows that. The comment was in the context of a patient with unexplained weight loss – and if the diagnosis was diabetes, that counterintuitively the treatment is more exercise and less caloric intake.

          • sFord48

            RE:  Doctors don’t want patients to market based decisions 
            Your don’t read many comments here on KevinMD?

            Like…”Consumer-directed healthcare, using HSA’s and all that, has been shown to bend the cost curve. People choose very wisely when it’s their own money.”

            Or the many posts of how unethical insurance and government involvement are and we would all be better off  with the same model a vet uses.

            Several years ago, I had unexplained weight loss.  I was training for track season at the time at had to stop running because I couldn’t get enough calories.  The costs of all those recommended tests nearly bankrupted my family.  I was never given a diagnosis or any advice on how to deal with the weight loss.  I learned my lesson.  I altered my diet to a high fat diet and my weight stabilized.  I have since gained some of the weight back.  

          • http://twitter.com/davisliumd davisliumd

            I agree if you had unexplained weight loss and had to stop running because you couldn’t get enough calories would be worrisome. When talking to my patients about Michael Phelps, the olympic swimmer, some of them told me the same thing – if they literally didn’t eat all the time they would lose weight because of the calories they burned. They were collegiate level players and if they weren’t sleeping they did three things all the time – swim, eat, and study. Phelps burns 4000 calories per day – over 1 lb per day. One can only wonder if that analogy applied to you and hence no final diagnosis.

            There are certainly a lot of comments on KevinMD. Some I agree with and others I don’t.

            Here are two I penned which appear on KevinMD and directly address the issue you quoted about consumer driven health care



            Thanks for sharing your story.

          • s_kthomas

            What about when there is no problem?  My 11-year-old grandson must have a physical in order to attend a week-long Boy Scout camping trip.  The least expensive place to get this physical (no insurance involved) is $140.00!  In my opinion that is outrageous and cannot be blamed on an insurance company!  How does this cost get justified when there is no complaint and no testing needed?  I was more than happy to shell out $140.00 to my pediatrician, who was/is amazing, but I was paying for his expertise, knowledge, years of schooling and my peace of mind.  $140.00 for a physical on a healthy, 11-year-old boy with no complaints, history or illness seems a bit steep. 

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

    There’s something I don’t quite understand about these recommendations. Don’t practicing physicians know these things already? They seem like pretty basic things, and certainly don’t warrant all the pomp and circumstance… Was this aimed more at educating patients? Or is this the foundation for the upcoming value based modifier calculations?

    • http://twitter.com/davisliumd davisliumd

       That is the question, isn’t it? Sounds like ensuring there is a basic “floor” of conversation and consistency that the medical organizations have communicated to the public so that there is common language for both doctors and patients.

  • buzzkillersmith

    Rubbish. This stuff represents tinkering around the edges, likely  a diversionary play on the part of the doctors’ trade groups. Really bending the cost curve will involve big-time cuts to subspecialist incomes, hospital business and drug and medical device costs.  It will involve re-design of the medical delivery system.  That won’t come from us docs.  It will come, if it does, from society. 
    Get real: Physicians are incapable of financially managing medical care given the current system.  Dr. Lui is either hopelessly naive or trying to fool us, or both. 

    • http://twitter.com/davisliumd davisliumd

      Agree with you that this initiative is unclear on whether it will make a difference in bending the cost curve.

      I’m not trying to fool anyone. Though I don’t know everything, I certainly hope I’m not naive.

      Within the current system, there are doctors trying to manage even better, are capable, and succeeding. Example are illustrated by the talented and award winning doctor writer Atul Gawande of Harvard in his thoughtful New Yorker piece Cost Conundrum.  http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

      He notes –

      …The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.

      …The core tenet of the Mayo Clinic is “The needs of the patient come
      first”—not the convenience of the doctors, not their revenues. The
      doctors and nurses, and even the janitors, sat in meetings almost
      weekly, working on ideas to make the service and the care better, not to
      get more money out of patients. I asked [Mayo Clinic CEO] Cortese how the Mayo Clinic
      made this possible.

      “It’s not easy,” he said. But decades ago Mayo
      recognized that the first thing it needed to do was eliminate the
      financial barriers. It pooled all the money the doctors and the hospital
      system received and began paying everyone a salary, so that the
      doctors’ goal in patient care couldn’t be increasing their income. Mayo
      promoted leaders who focussed first on what was best for patients, and
      then on how to make this financially possible….

      The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores….

      Grand Junction’s medical community was not following anyone else’s
      recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth,
      calls an accountable-care organization. The leading doctors and the
      hospital system adopted measures to blunt harmful financial incentives,
      and they took collective responsibility for improving the sum total of
      patient care.

      This approach has been adopted in other places, too:
      the Geisinger Health System, in Danville, Pennsylvania; the Marshfield
      Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake
      City; Kaiser Permanente, in Northern California. All of them function
      on similar principles. All are not-for-profit institutions. And all have
      produced enviably higher quality and lower costs than the average
      American town enjoys.
      The question is will all doctors organize similarly and take the challenge?

      • buzzkillersmith

        Davis, you really have to give this incredibly naive crazyhappytalk a rest if you want to be taken seriously.  You’re giving us examples of aberrations, examples of things that rarely happen.  You’re a doctor, you know that the numerator is meaningless without the denominator. Hello, I’m talking about things that do happen and have happened.  
        Read some economics read some history, doc, and upgrade your analytic skills.  Incentives, Davis, incentives.  
        I stand by my statement: The medical profession will have to be dragged kicking a screaming by a fed-up society. I suspect the outcomes won’t be pretty for us docs. 

      • southerndoc1

        Dr. Gawande would do much better to put some energy into examining the extortionist contracts that the hospitals he practices in have forced on the insurers.

      • southerndoc1

        And I would encourage you to review a couple of EOBs from Mayo on non-Medicare patients. And check out Elizabeth Warren’s investigation into the disproportionate number of patients Intermountain has forced into bankruptcy.

      • lissmth

        ACO (accountable care organizations) are nothing more than capitated HMOs and we all saw how wonderful they are.  I am in Colorado.  People do everything they can to avoid Rocky Mountain Health Plan HMO.

        Why not HSAs, transparent pricing, and high-deductible plans for all?

        • davemills555

          FALSE! An ACO is an organization that employees health care professionals (doctors, nurses, lab technicians, etc.) as “salaried” employees. The primary reason they will exist is to offer the health care consumer something other than our failed fee-for-service delivery model. As a matter of fact, my primary care physician is currently negotiating the sale of his practice to an ACO. When the sale is complete, he will join the ACO as a salaried employee. As a salaried employee of this very large (6 hospital) ACO, he will enjoy regularly scheduled hours, scheduled vacations, a pension plan, paid health insurance and dental insurance for himself and his family, the opportunity to participate in a company sponsored 401k plan, paid holidays and much much more. ACOs are nothing like HMOs of the past because HMOs of the past didn’t eliminate the failed fee-for-service delivery model. The downside? Small solo-doc Marcus Welby type practices will find it very difficult to compete with these massive big box health care warehouses. What WalMart did for retail shopping, ACOs will do the same for health care delivery.

    • davemills555

      I agree. The cow is almost run dry and the goose that lays the golden eggs is on life support! The industry has no incentive to bend the cost curve.  None! Insurance companies and their trade groups, doctors and their trade groups, hospitals and their trade groups and drug and medical device companies and their trade groups have all contributed to the collusion of the past and those that didn’t actively participate in the corruption, actually contributed to it by turning a blind eye, remaining silent, and allowing it to happen. In Vermont this week, we are finally seeing a version of S.88, “AN ACT RELATING TO HEALTH CARE FINANCING AND UNIVERSAL ACCESS TO HEALTH CARE IN VERMONT”,  come to the Senate floor for debate and a vote. Single-payer is the only way to stop the corruption within the industry. Any other measure that continues to allow the “foxes to run the henhouse” is just tinkering.

  • lissmth

    As all these societies continue to fall into line, I have to wonder if they are all government financed.

  • katerinahurd

    How do you explain rejection of concierge medicine, but not endorsement of preventative medicine?  Do you think that the techno- affiliation of physicians and medical technology stems from a culture that survives according to the principle; to see is to believe?  Do you recognize the similar influence of a patient’s talk with his familiy and general practitioners talking to specialists?  Do you agree that he art of listening is lost in the doctor- patient relationship? 

  • davemills555

    Who’s responsible for bending the health care cost curve? In my opinion, we all have skin in the game. Consumers, doctors, hospitals, pharma, medical device companies and greedy insurance companies. Of this list, the one we need the least and the one that brings absolutely no value to the table are the greedy insurance companies. Nobody can explain why they exist. Especially in the age of the Internet where shopping for health insurance is not rocket science. The sooner we eliminate insurance companies from the mix, the better off we will be. 

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