Simple way to cut cost
Doctors should order fewer tests and procedures. Many of them are unnecessary.
By Richard Fried
Medical doctors have it within our power to substantially eliminate the current health-care crisis - overnight, and without legislation. How? By eliminating unnecessary tests and procedures.
Sound simplistic? Here are but a few examples of the absurd way medicine is practiced in this country, drawn randomly from my daily experience as a family doctor trying to practice sustainable medicine:
A patient came in with a small, soft lump in her cheek. Her dentist ordered an MRI and referred her to a surgeon, who ordered a CT scan and, some months later, another MRI. From feeling it, I could immediately identify it as a lipoma, a harmless, fatty growth. So I called the surgeon to find out why he had run all the tests. He didn't really answer, but admitted he knew all along that it was a lipoma. The cost of the scans: more than $10,000.
The U.S. Preventive Services Task Force recommends screening women of average risk for osteoporosis starting at age 65. Yet most gynecologists begin screening at or near menopause. The yield? You would have to screen more than 4,000 women aged 55 to 59 over a five-year span to prevent one hip fracture - at a cost of $2.8 million.
Emergency rooms routinely perform CT scans on patients with abdominal pain or head trauma. However, if these patients saw their family doctor instead, they would be examined and most likely sent home with directions on what symptoms would indicate the need for more testing. The cost: $1,800 for a CT of the head, $3,400 for the abdomen (not counting charges for the ER visit).
According to a recent report by PricewaterhouseCoopers' Health Research Institute, up to $1.2 trillion of the $2.2 trillion spent on health care annually represents wasteful spending.
Why do we order so many unnecessary tests and procedures?
First, medical training emphasizes thoroughness. Nobody is criticized for ordering too many tests, but wrath and humiliation fall upon the student who fails to consider a possible diagnosis and order the relevant tests. Unfortunately, this approach is economically unsustainable.
A second explanation is financial self-interest. Gastroenterologists universally recommend colonoscopy over fecal blood sampling for routine colon-cancer screening, even though there is no good evidence that colonoscopy is a superior method. The difference in cost, however, is huge.
Dermatologists recommend routine, yearly skin surveillance in older patients, at a cost of $250 or more for an exam and biopsy. The Preventive Services Task Force, however, has concluded that there is insufficient evidence to recommend for or against this procedure.
Unnecessary procedures are often blamed on "defensive medicine" designed to head off lawsuits. While I'm sure this plays a role, it's also a convenient way for doctors to duck the blame.
I believe the chief problem is that those ordering the tests and procedures are totally divorced from responsibility for the resulting financial burden. Like polluting industries, we earn our profits and serve our constituency (for us, patients rather than stockholders) and leave the toxic consequences to others downstream.
Unneeded tests and procedures are not only economically unsustainable; they also represent bad medicine, increasing the risk of unnecessarily invasive procedures, raising unnecessary fears (which, ironically, only more tests can alleviate), and contributing to physician burnout.
President Obama has identified health care as the greatest threat to our economic future, so here is my recommended solution. To my colleagues: Before you reflexively order that test, talk to your patient, and use the clinical problem-solving skills we all learned in medical school. You'll actually reduce the likelihood of a malpractice suit and find you are enjoying your practice more at the end of the day.
To patients: Question the need for expensive and invasive procedures. They may well cause you more harm than good. Avoid feeling you have a "right" to a test because you are paying such high insurance premiums. I reckon that every unnecessary CT scan or MRI helps force one more person into the ranks of the uninsured.
Some will say this is a naive, "Just say no" solution to the crisis, destined to be no more successful than Nancy Reagan's proposed cure for teenage drug use. But can it really be that we are no wiser than that target group? Would we really prefer government regulations and their unforeseen consequences?
It is ultimately in our self-interest to reduce wasteful medical care. It's also, by the way, the right thing to do.