This blog is devoted to an examination of medical quality. Cost-effectiveness is woven into many of the posts as this is integral to quality. Most of us reject the rational argument that better medical quality costs more money. Conversely, I have argued that spending less money could improve medical outcomes. Developing incentives to reduce unnecessary medical tests and treatments should be our fundamental strategy. Not a day passes that I don’t confront excessive and unnecessary medical care – some of it mine - being foisted on patients.
At one point in my career, I would have argued that physicians and hospitals were motivated only to protect and preserve the health of their patients, but I now know differently. Payment reform changes behavior.
As an example, it is impossible for a patient with a stomach ache who is seen in an emergency room to escape a CAT scan, even if one was done for the same reason months ago. I saw a patient this past week with chronic and unexplained abdominal pain. She has had 5 CAT scans for the same pain in recent years. This is a common scenario. Once reimbursement policy changes to punish physicians and hospitals for overtesting, we will witness the Mother of All Medical Retreats!
Are 5 scans enough?
Physicians and the public have an interest in preserving medical resources to serve society. There is an emerging debate if physicians who are counseling patients should be mindful of society’s needs while in the exam room. In other words, if I am prescribing a medicine for a patient with Crohn’s disease that costs $25.000 annually, should I also be considering if this is a wise use of society’s resources? Would this money be better spent giving influenza vaccines (‘flu shots’) to uninsured or medically underserved individuals? If you were my patient, do you expect that I am focused exclusively on your medical interests regardless of the cost? Do I have a responsibility to consider how my advice to you impacts on others’ health since health care dollars are finite? Should patients be willing to sacrifice their own medical care in order to serve the greater good?
Cost-effectiveness is presumed if someone else is paying the bill. If patients had some skin in the game, then they would exert some restraint on the current frenzy of diagnostic testing and treatment. If my patient cited above had to pay a portion of the 5 CAT scans that she had undergone, there may have been only one scan. And, if the hospital and the radiologists were paid only for necessary testing, there would have been a similar outcome.
More medical care often means lower medical quality. How much longer do we want to pay more to receive less?