Physicians are the biggest driver of health costs

There are many reasons to be dismayed by the error-filled and managerially incompetent rollout of the federal health insurance exchanges that are in many ways the linchpin of President Obama’s Affordable Care Act. I sympathize with commentators who have called for the resignation of Department of Health and Human Services Secretary Kathleen Sebelius. It’s hard to imagine Franklin Roosevelt not firing someone in his cabinet had social security stumbled this badly out of the gate, or Lyndon Johnson not causing officials’ heads to roll if the launch of Medicare and Medicaid had been so mangled.

Still, I believe that throwing the baby (the ACA) out with the bathwater (government officials) would be a huge mistake. Health care costs will continue to rise with or without the law’s implementation, consuming an ever greater chunk of the struggling U.S. economy and causing government budgets to run into the red regardless of any future grand bargains on taxes and spending. The status quo stinks, and doing nothing is not an option.

Some of my physician colleagues have argued that the major problem in medicine today is that restrictive insurance companies and armies of utilization reviewers have curtailed our independence. Return decision-making power to doctors, they argue, and the system will run more efficiently. When surveyed recently about who had “major responsibility” to control health care costs, U.S. doctors called out trial lawyers, insurance companies, hospitals, drug and device manufacturers, and patients. Only one in three pointed the finger at themselves.

In an editorial in the New England Journal of Medicine, family physician Cheryl Bettigole takes the opposite point of view. Noting how a $20 to $30 Pap smear can be transformed into a battery of tests (some unnecessary) that cost hundreds or even a thousand dollars, she argues that physicians have the primary responsibility for protecting patients from financial harm and being good stewards of health care resources:

So how do all these tests come to be ordered for healthy women who come in only for an annual gynecology exam? The answer is that someone, whether the physician or nurse practitioner or the medical assistant processing the specimen, checked off all those boxes on the order form … When I was in training, our attendings would ask a standard quiz question: “What is the biggest driver of health care costs in the hospital?” Answer: the physician’s pen. A mouse or a keyboard, rather than a pen, now drives the spending, but we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.

Yes, the U.S. health care non-system provides physicians with numerous incentives to “do the wrong thing” in patient care. The more services we provide, the more money we make. Pharmaceutical representatives persuade us to prescribe expensive new brand-name drugs over more effective and affordable generics. Indecipherable medical bills and insurance statements often prevent patients from knowing how much their care costs until they’ve already received it. But these challenges should not be excuses for inaction on the part of practicing physicians or those in training.

As Dr. Bettigole writes:

We need to teach medical students and residents to see [good financial stewardship] as an important aspect of their responsibility to their patients. Furthermore, we need to advocate for a system in which information about the cost and benefit of diagnostic tests is readily available to patients and providers at the point of care. If we fail to do so, we risk not only our patients’ pocketbooks but also the gains we have made against cervical cancer and many other conditions. We contribute to spiraling health care costs and are doing real harm.

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

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  • JPedersenB

    Amen to that! However, when a patient questions their doctor on the necessity for all the tests, one usually encounters a very angry doctor or gets stone-walled (or dumped). As was pointed out, sometimes patients are not even told which tests are being ordered and then only find out upon receiving the bill.

    If we are ever going to get this run-away train under control, we all must change!

    • rbthe4th2

      Amen to this post! I’ve been the brunt of it LOTS of times. The other is that if I could get appropriate testing, that is more helpful than a bunch of docs doing the same thing and telling me I don’t have something, than giving me the appropriate tests.

  • Shirie Leng, MD

    Yes and no. I fully agree that medicine has buried it’s head in the sand and hoped that the cost issue would just go away. Because we didn’t address it, it’s being addressed for us in ways we don’t like. Because we doctors generate the orders and prescriptions, of course our line item is the biggest. But we cannot practice fiscally responsible medicine on our own. Patients and lawyers must do their part. For example, the rise in obesity is partially to blame for the escalating costs associated with the health problems that result. Doctors are not responsible for the behaviors and diseases that result in their orders and prescriptions. Healthier patients makes for less expensive medicine. And “just in case” medicine will prevail as long as the fear of legal action hangs over our heads.

    • DSAiANP91870

      Doctors still subscribe to the lipid hypothesis. They are responsible, in good part, for the obesity epidemic. They are not as responsible as food companies and all those who promote the eating of highly processed fake foods but they need to become educated and informed about what works and what does not.

      I am not convinced that all doctors want healthy patients. I am convinced that drug companies want large populations of the chronically ill.

      After all, without unhealthy people where are revenues and profits and the new sports car going to come from. The threat of legal action is highly exaggerated. The best way to reduce the 2% of health care costs that are associated with medical malpractice is to stop malpractice.

      The ACA puts a spotlight on the glaringly obvious: we need Medicare for all before the health care industry sinks the economy for generations to come.

    • EE Smith

      “Healthier patients makes for less expensive medicine.”

      I am very healthy, thank you. That still doesn’t save me a dime, when the nurse in my PCMH ticks every single box on the pap test form (including those for diseases I couldn’t possibly have) and I end up with a $1200 bill.

      • Shirie Leng, MD

        Absolutely agree with you. No question.

    • rbthe4th2

      Agreed. However, covering dietary services and the like would be HUGE first step in helping that issue.

  • eqvet2015

    I have multiple chronic conditions and spend more time, money, and energy than I can really afford going to various specialists. I recently questioned one of my doctors about the utility of a certain test she wanted me to get. When asked directly, she admitted that the result was not going to change her management of my case, but said that it was considered standard of care for most patients to have this lab result and she would be questioned by her superiors for not ordering this test. She was unwilling to consider forgoing the test. As a patient, I have very little power over this sort of thing, and changing specialists requires additional money, administrative hoops to jump through, and a wait of one to three months, with no guarantee that the next person is going to be as good, let alone better. I ask questions but don’t make big waves if I’m overall getting the care I need to get better.

    As a vet student, many of my patients are not covered by insurance, and most owners are quite cost-conscious. It is drilled into our heads that we should ask ourselves – and be able to justify to the client, as they often ask us – what the test is going to tell us and, more importantly, what we are going to do with that information. If you admit it’s not going to change your management, good luck convincing an owner to do it.

    • Deceased MD

      just say no. Nancy Reagan did. No one can force you to get a test that does not make sense to you. She can still be your treating physician.

      • eqvet2015

        What is a patient to do, though, when a doctor says they won’t continue to prescribe a necessary drug if the patient refuses a test? I’m not trying to be difficult, I honestly feel stuck. I went to multiple primary care doctors before finding a doctor who is fantastic (and has great colleagues who cover for her when she’s out), but when it comes to specialists, I settle for them knowing their medicine and compromise on the rest.

        • Deceased MD

          oh I guess that is tough if it involves medicine that you need.

          • rbthe4th2

            and that’s exactly what we deal with Deceased. I’ve seen great docs post on here, I just wish they operated in my neck of the woods. I’m sure we’d be able to get along instead of the paternalistic egos I’ve been exposed to.

          • Deceased MD

            Thanks for explaining that rb. I learn a lot myself from reading your posts. If it was for your own welfare that would be different.

            Sounds like it comes across rather dogmatic. Is your doctor Obama?

          • rbthe4th2

            I think you’d learn a lot from reading my medical records, but they’ve got items in there that are less than accurate. Months later, I’m still fighting trying to get items corrected. If you reviewed medical literature, and my situation, you’d find out every time, there was a physical issue that needed addressing.
            I realize people present in different ways. I would be very happy if I could get a doctor who could understand the clues as to how we figure things out and help. I’m not the only one on here who is dismayed by a lot of the us vs. them attitude, when we could accomplish so much working together.
            I don’t know to be honest. I know it doesn’t help when I point out some of the basic obvious things that should have been taken care of in medical school. Reading labs for example. If I just bring something to someones’ attention with a reference, it sets physicians’ teeth on edge. If I bring up a reference, ask the question how does it relate to this particular reference showing X is not the best indicator of Y, I’m looked at like I have 3 heads and they want to toss me out.
            Any ideas?

          • Deceased MD

            Wanted to make sure I understood. So when you bring up your own ideas they get threatened?

          • rbthe4th2

            Yes and no.
            As an example, when I say I have this study and it says that this lab value will be still be normal even with this underlying condition, and I have other symptoms of the underlying condition, can we test other items (such as indicated in another study) to see if that’s the problem.
            Or if I ask how does that relate to this symptom, because every study I have seen says X symptom is a condition of Y. They’d shake their head and say no and I would ask based on what, and then I’d get some sort of negative look or response or change the subject, but the question would never get answered.
            Or these symptoms can also be an issue for X, and I get “no recommendations”. However, another doctor can test and has found other problems.
            Another was when I questioned a treatment. I said if I have X problem, shouldn’t I need this medication with this particular dose? This is what I read works for someone with what I was diagnosed with.
            Again, all these examples go back to having medical literature as the basis. I’m looking for physicians to look at this and tell me where to look so I follow their line of thinking, what symptoms are a problem, what to look for, etc. and I just get brushed off.

          • Deceased MD

            I’m sorry to hear that. Maybe an academic center would work better to discuss more evidence based medicine. Maybe you have already tried this.

          • rbthe4th2

            You are kidding right? I’ve heard it before, we can’t figure it out, an academic center can. You really mean that regular docs can’t look at 2-3 literature references and figure it out?
            The problem is expense and travel. There’s not a decent college (the one in town, with all due respect, is not Johns Hopkins) except a few hours away.
            The other issue – what happens once they’re done? I can’t just travel on up every month or so when there is a problem. Would a specialist tell a regular doc or specialist doc in my area what to do?

      • rbthe4th2

        With all due respect, Deceased (and I enjoy your posts, whether or not we agree/disagree), I was forced into taking a test and protested it. I was told if I didn’t take it the doc wouldn’t see me, and I would be charged for that visit as a noshow. I’ve also refused tests before and it was used to say I was noncompliant (when it would NOT have made a difference in my care, I found out) and boot me out.

      • May Wright

        “No one can force you to get a test that does not make sense to you.”

        That is not quite true, because doctors can hold other services “hostage” to force their patients to do what they want. I was talking to one woman whose doctor **would not** renew her prescription for simple birth control pills without the woman subjecting herself to annual “well woman” exams. Forcing women to have annual pelvic exams, breast exams and pap smears in exchange for “allowing” them to get birth control pills is not that uncommon. And for women in insurance plans with very limited provider networks, it’s not always possible to just “change doctors”.

        Doctors have a government-granted monopoly which allows them at act as “gatekeeper” for a number of pretty basic things — such as BC pills or, as John Hunt mentions above, lab tests and such — and that gives them a lot of power. There’s been a lot of talk about “hostile dependency” here lately, and things like the “strip and get in the stirrups or you can’t have your birth control pills” game — and then calling your patient an “acting-out hostile teenager” and slapping a big red “DIFFICULT PATIENT” sticker on their permanent record when they don’t meekly submit — are not helping matters any.

  • John Hunt

    Anything that increases moral hazard will increase health care costs. Anything that decreases moral hazard will decrease costs.

    It is not the doctor whose primary duty is to control costs. It should be the patient’s responsibility to determine, with the advice of their doctor and their own internet research and their knowledge of their finances, and the knowledge about themselves, how to apportion their spending between different sorts of health care, food, housing, dining out, lottery tickets, vacations, etc. We as doctors have an ethical obligation to not defraud our patients by selling them stuff that we don’t think they need. But sitting idly by and charging OTHER people (insurance companies and taxpayers) isn’t the answer. Price controls is not the answer. Giving the decisionmaking responsibility to the useless bags of political flesh isn’t the answer.

    The diagnosis for our health care problems is that health insurance is the cause of the disorder. We can’t cure the disease if we make a wrong diagnosis. So let’s get that clear.

    And then we need to excise the tumor that is health insurance. And start using the much better ways to help the poor, as opposed to just forcing them to buy crappy health insurance products.

    Health insurance is the problem, not the solution.

    • EE Smith

      I agree with your comment wholeheartedly, and just wanted to add that whenever I hear someone proposing price controls, I remember the most miserable vacation I ever had as a child, a driving vacation/road trip with much of our time spent waiting in lines at gas stations, courtesy of price controls.

      George Shultz: “And one thing you know from experience is when you control the price of something, you end up getting less of it.” Quite so.

  • John Hunt

    Costs are far far too high now, because of the third party payment system. All costs come down, hard and fast, when that bloated system gets replaced by simple catastrophic insurance. The government has subsidized and now demanded health insurance–causing moral hazard. Instead, the people should have FINANCIAL insurance, to protect against the troubles that you state above. And that means catastrophic insurance. When people pay their own money, entirely, for all their non-financially-catastrophic care, then the downward prices pressure from these ridiculously inflated prices will be pronounced. Patients are much much much more conscientious about their use of resources when it is their own money being spent. It is absolutely the case.

    • Mike

      “Patients are much much much more conscientious about their use of resources when it is their own money being spent.”

      See also Milton Friedman’s lesson on the four different ways to spend money:

      1. You spend your own money on yourself.
      2. You spend your own money on someone else.
      3. You spend someone else’s money on yourself.
      4. You spend someone else’s money on someone else.

      There’s a good chart and a youtube video of him explaining the relative efficiencies/inefficiencies of each.

    • rbthe4th2

      I would disagree with this. Recently I’ve attempted to get testing that costs in the range of $700-$1K. I just got a doc to agree to this testing. Instead, insurance and I have blown through $10K paying for all the visits, medications, treatments, when if we did the tests I requested in the first place, we wouldn’t have spent $10K. We’d spent the above amount and would have been able to pinpoint the issues and fix them at a cost of about $75-$100.
      I was the one who said I couldn’t visit a doc because I didn’t have the money. They responded by saying I needed to get another doc.
      So how are we supposed to be conscientious, when we’re not getting cooperation from physicians?

    • Steven Chaisson

      What do you think a health insurance plan on the Obama exchange with a $6,000 deductible, that is catastrophic insurance to most people. Most people couldn’t save $6,000 a year, yet allow save that for medical procedures. If we pay more out of pocket, you guys will not get paid $400 for immunizations, like my two kids cost this year.

  • Leana Wen MD

    Thanks, Dr. Lin, for the article. Physicians need to be good stewards of healthcare costs, and have to
    engage patients in a real discussion about the costs of care. Part of that discussion needs to
    be up front disclosure about why they are recommending what they are
    recommending–if the doctor is getting paid for the hip replacement but
    not getting paid if I don’t get the surgery, I want to know that,
    because that factors into whether I trust that recommendation.

  • birchpoint5

    A lot of Docs order tests because they don’t want to be sued. Any time you want to know who is in charge of a situation, follow the money. The insurance reimbursements are not realistic and the hoops to be jumped through are multiplying like rabbits; lawyers make a ton of money from frivolous lawsuits ( they get more out of it than the patients in many cases. So, are some docs pushing the envelope? Yes. But others bear most of the responsibility.

  • Michael Wasserman

    You are 100% correct. What’s worse is that the government uses our taxpayer dollars (from the Medicare program, of all places) to subsidize the training of physicians to perpetuate this expensive system. I’ve practice a high touch, low tech form of medicine my entire career, with good outcomes, but have often been looked down upon by my fellow physicians. Fortunately, my patients are the ones that matter to me the most!

  • Michael Wasserman

    Guess what? The AMA determines physician reimbursement through a committee called the RUC. That committee is made up over 85% with specialists. Who do you think gets paid the most?

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