Sunday, September 26, 2010

Cost Effective Medicine: A Lesson from the Legal Profession

Missouri, the ‘show me’ state, is showing the country an interesting and novel concept. Judges there will be apprised of the financial costs of various punitive options before issuing a sentence. For example, a judge would be informed that a convicted drug user could be sentenced to 5 years in prison for $50,000, or could do community service with a probationary period instead for a fraction of the cost. Blind justice? This new policy has generated spirited debate. Some welcome the reform, which aims to bring some measure of cost sanity to the justice system. Others oppose the effort arguing that justice must be meted out without regard to financial costs.

Is this issue being driven by difficult economic realities? Some are hostile to incarceration for reasons independent of its exorbitant expense. These folks favor rehabilitation and treatment over confinement as a matter of policy. Is there any cost of justice that is too high?

I viewed this report through the prism of a practicing physician, a member of a profession that spends much too much of other people’s money. Similar arguments against cost control are made by those who feel that medical costs should not be a factor when treatment options are being considered. This point of view is the backhoe that has dug a hole so deep, that we can barely see daylight. Patients never ask me about the cost of my recommendations when their insurance companies are paying the bill. When I was a medical resident, I recall when tissue plasminogen activator (TPA) was launched for the treatment of acute myocardial infarctions. It cost a fortune, compared to the existing clot buster streptokinase, and had no significant advantages with regard to safety or efficacy. This seemed irrational to a 2nd year medical resident, but my confusion must have been the result sleep deprivation. In general, new medical stuff costs more, but doesn’t necessarily do more.  The New York Times this past week reported on a controversy on cost effectiveness published in the current New England of Medicine issue.  The reporter writes: How much should healthcare providers pay for expensive treatments that make relatively small improvements?  The Times article caught the attention of Medrants, who offers his own commentary on the issue.

For those who are not lawyers or physicians, consider an everyday example of what occurs when you can charge a bill to someone else’s credit card.

First Example: A hardworking Dad takes his wife and 2 kids out to dinner.
“Okay kids, order off the kids’ menu and Mom and I will share the early bird special. Drinks? Nothing more refreshing than ice cold tap water!"
Second Example: The same Dad, who is salesman, meets a client for a dinner meeting.
“Bring us a second bottle of that wine. Foie gras? Never had it before, but bring it on. I’ll have the steak tar tar appetizer and then the filet mignon, the larger size. I can always bring it home it it’s too much…”
Cost consciousness has never gained respectable traction in medical practice in physicians’ offices or hospitals. Doctors dispense expensive care to patients and send the bills elsewhere. No wonder so many folks expect and demand ‘foie gras’ medicine. And we physicians are happy to serve it up to them.

I have argued previously that if patients had some financial ‘skin in the game’, that it would serve as a brake on overutilization. Patients and families would make different decisions with regard to experimental treatments, end of life care and endless diagnostic inquiries, if they bore some measure of the cost of these endeavors. Of course, we do not want to deny sound medical care on the basis of cost, but cost must be a consideration. Isn’t this what every one of us does when we are shopping, taking a vacation or buying a car?

If we physicians were apprised of the cost of our medical recommendations, similar to Missouri judges, it might influence us when we advise patients. At present, we order tests and medications with no price tags attached. We physicians often don’t know the cost of our diagnostic and treatment plans. If we did, perhaps, certain remedies, such as a tincture of time, would gain currency in our offices.
Here are a few examples:

For a patient with hypertension:

The ‘New & Improved’ Blockbuster           $600 per year
Diuretics (water pills)                                    $30 per year

For a patient with C. difficile colitis:

Vancomycin                       $750
Flagyl (generic)                    $13

For a patient with an upper respiratory infection

Avelox                   $80
Doxycycline          $14

For a patient with a headache:

CAT scan of the head          $700
2 acetaminophen tablets      19 cents

My pricing may not be entirely accurate, depending upon one’s insurance status, formulary discounts and other discounting. But, you get the idea. Imagine how much health care reform would erupt if the cost of our medical advice, including the alternatives, flashed on a big screen in our exam rooms, and the patient was responsible for a fair share of it.

I think that Missouri has a lot to show us.

Your thoughts?


  1. Diagnositic yield of CT of the head for intracranial pathology: occasional.

    Diagnostic yield of two Tylenol: 0.

    Be very careful or soon we're be looking up numbers in the QALY ledgers to guide our therapy. No Hippocratic physician really wants that, I think.

  2. I agree that physicians don't know enough about the relative and absolute costs of procedures and treatments. But I'm not sure it's right, or always right, for patients to pay for care based on how much they use. People with cancer, for example, really do need and benefit from some very expensive drugs. A teenager in the ICU after a near-fatal car accident will run up gigantic bills, regardless of whose fault it was.

    Maybe the solution demands that physicians be more aware of prices and evidence, as you suggest, but that the costs be born collectively.

  3. @AB, agree that acetaminophen has rather limited diagnostic potential. However, I think our profession, including me, orders too many diagnostic tests. @ES,I appreciate your point. However, if the patient bears no financial responsbility for his care, then he has no incentive to pursue a reasonable and judicious testing and treatment pathway. To use the restaurant analogy again, if the proprietor tells you that your meal is 'on the house', guess what happens?

  4. Here's a link from USA Today on some very pricey medical treatments. Money well spent?

  5. I can barely disagree on this post, these days lots of Hospitals are indulging in unnecessary costlier treatments and medicines, which does not have any significant advantage over the conventional or low cost medicines.

  6. I agree with the fact that people overuse treatments and corporate credit cards when someone else is fitting the bill. With the implementation of Obama care, the government will be taking on more of the burden of the un-insured/underinsured. Will spending go up when more tax dollars are directed at medical care?
    Were on the ledge of a pending health care crisis in our country and everywhere i look i see new hospitals and surgery centers sprouting up all over the Cleveland area. In my practice, I see 95 year old bedridden patients getting cataract surgery; 90 year old bedridden patients getting hip replacements..........If some of the financial responsibility was put back on the patient and their family, do you think these procedures would have been performed? As a country, we have very difficult decisions ahead of us regarding health care utilization and spending. As Americans, we want it all; but can we afford it???

  7. Generally, drug users rarely go to prison for 5 years. Drug DEALERS may and should because that is a seperate crime.

    However be that as it may, people who are addicted to drugs will go right back to using drugs once they are released. The only thing that worked was a pilot program years ago that set up convicts with new jobs in other parts of the country.

    The key was that they were away from their old element (friends, etc) who did drugs and had a job. This saved the taxpayer money and worked.

    People got upset that the government was finding jobs for convicts and the program was scrapped.

  8. Sometimes I wonder whether, when a patient becomes too demented to make decisions or becomes permanently unconscious, Medicare should stop paying. I've seen families go back and forth endlessly about whether to withdraw life-prolonging care on their cancer-ridden, demented or comatose parent--even when the patient had explicitly stated that they did not want extreme measures! Maybe they would be a bit less spendthrift if they had to weigh the value of torturing Mom for another week against the value of sending junior to college. It's not the whole problem, but for me, the most appalling fraction.

  9. On another blog you asked about how entrance to med school could be vetted for qualities other than academic ability. Since comments are closed there I will answer here. Our school uses academic standards and something called Multiple Mini Interviews (10). We are very pleased with the results.

  10. DeirdreB, thanks for the link. Interesting stuff from up north!