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?