Sunday, March 31, 2013

Medical Overdiagnosis and Overtreatment - Do Physicians Want Cost Control?

Truth is more absurd than fiction.  Mayor Michael Bloomberg’s wacky ban on certain sizes of sugary beverages, a scheme which was riddled with inconsistencies and exceptions, was properly squashed by a New York judge.  The mayor’s next play was to order all establishments that sell cigarettes to hide them from patrons.  I hope that this policy is examined in the same courtroom that ruled that the leaky soda ban was illegal.  Is this guy a mayor or an emperor?  Who can legitimately defend the government dictating to private businesses how they can display legal products to its customers?  Where would candy, potato chips and other poisonous snack foods be sequestered? 

Speaking of sequestration, which the president warned would crush the country, the earth still rotates, the sun rises in the morning and congress has a 15% approval rating.  In other words, not much has changed. 

We learned that there was not enough cash to fund White House tours for school kids.  Yet, we learned that Vice President Biden and his entourage spent $585,000 for a single night in a Paris hotel last month.  The VEEP & Co. were more frugal when they stayed in London on the same gig when the price tag for one night was a mere $459,000.  This seems a smidgen extravagant during such economically lean times and conveys a message of prodigal excess to the hoi polloi.   Is it possible that some of the expense for these 2 nights was excessive?  Was every government official on this junket essential to advance American interests?  While I don’t suggest that the VEEP stay in a Bed & Breakfast or a youth hostel, I’ll bet that these obscene hotel costs could have been reduced without jeopardizing our foreign policy interests.
$585,000 + $459,000 = Lots of White House Tours for Kids

 Motel 6 Next time?

I know from my own profession how many zillions of dollars are wasted that generate income for various constituencies but don’t advance the greater good.  I have admitted repeatedly that I and my colleagues are one of these constituencies.  While the phrase cutting waste is an attractive populistic utterance, the substitute phrase cutting income is more provocative.   Every dollar of waste is someone’s income who likely doesn’t view his earnings as wasteful spending.  Of course, this is not particular to the medical arena; it’s true of every profession, trade and institution.

I have railed in this blog about the explosion of unnecessary radiology testing in medicine.   CAT scans of the abdomen have largely replaced physicians’ examining abdomens, similar to how echocardiograms have replaced actual physicians discerning subtle heart sounds and murmurs with the antiquated medical instrument known as a stethoscope.   While those who overdiagnose and overtreat, including gastroenterologists, justify their practice patterns as sound medicine, watch these practice styles screech to a halt once punitive payment policies against medical overuse are implemented. 

This week I saw a patient with abdominal pain who had a normal ultrasound of the abdomen 2 days prior to hospitalization at another institution.  The dictated report was on the chart for all to review.  The attending physician had ordered a special gallbladder test, but the radiologist had insisted that an ultrasound be repeated first.   Did we expect that a 2nd ultrasound 48 hours later would show new findings?

I see this stuff every day and it is these observations that led to the creation of this blog.  There is waste in the care of every patient, including mine, but the system has been immobile and immutable.  The medical industrial complex is a lumbering ocean liner whose course extraordinarily difficult to alter.  Every real reform threatens powerful, highly motivated and well-funded players. 

Obamacare has smashed through the barricades and promised to be the panacea that eluded us for over half a century.  I have been a deep skeptic and my skepticism has deepened with time, along with the rest of the country.  Let’s watch what actually happens to medical costs and quality as the government rules and regulations coerce doctors, patients and employers.  When the myths of Obamacare are exposed, will the president come clean to our kids when they are finally allowed to visit the White House?


  1. As usual your observations are spot on. I would even take them a bit farther in that what is likely wasteful is viewed as being best practice. Repeating the ultrasound is viewed as being careful and compulsive despite the realities that it may be driven mostly by rent seeking and virtually never actually adds value (except to the operator). Not to be piling on to Radiology since this is not unique as all to them. In our own anecdote driven way we (in the broadest sense we) end up using our most lucrative and highest margin tools repeatedly based upon the medical version of the precautionary principle...better safe than sorry. It conveniently morphs into money making schemes.

    In a world where patients are insulated from the costs of this type of thinking they will also view it in a positive light since at first blush it appears to be operating also in their best interest. It will be devilishly hard to change since there are no rapid feedback loops which affect the participants in any meaningful way in the short term.

  2. 2MC: First, where have you been? Your erudition has been missed. "As usual, your comments are spot on." I agree that the system is screwed up with incentives that are operating at cross purposes. Obamacare is blowing it up. I fear what will emerge.

  3. Great Job. I too am very skeptical of how all of this will play out. I hate the fact that some of these rules are happening on the fly leaving many in the dark about whats to come.

  4. This week I saw a patient with abdominal pain who had a normal ultrasound of the abdomen...

    Then, was it not your responsibility to tell the patient they should forgo another ultrasound?

  5. I'd be interested to see a list of the expenses incurred on those overseas stays. Those bills are absurd.

  6. The incentives and real-time transparency just aren't there. If the patient knew that every test/treatment was associated with a substantial co-pay (and knew up front what that co-pay would be), if the hospital knew that every duplicated test/unsuccessful treatment would erode profit from payments for good outcomes based on admitting complaints, and if physicians knew that every test/consult/unsuccessful treatment comes with a percentage reduction in reimbursement, we would all have an incentive to think twice about doing the unnecessary. Until then, we will continue finding justification for everything, since it isn't very difficult. With more conservative approaches to evaluation & management, there would almost certainly be enough savings for physicians to make MORE money by making smart decisions.

  7. @Mark Faasse, MD, I respectfully disagree that "incentives and real-time transparency just aren't there" from a patient's perspective.

    My experience has always been a "I didn't know I had to ask that question" consequencing cognoscible financial punishments.

    HSA type medical insurance involves a learning curve and demands a physician's transparency.

  8. Would you mind sharing an example of your experience, Anonymous?

  9. I handle the contracting with payers for a 250 doctor independent medical group, and am active in MGMA. I am in Indianapolis.

    The issue is complex, but I believe more and more patients (but still a small percentage) are starting to ask: "How much will this cost and how will this affect your treatment decision?"

    And providers should be ready to ask patients: "How will you pay for this?"

    MD's need to be like the DDS's who everytime I've been to the dentist, eventually someone tells me: "Here's what we recommend and here's what insurance will pay and what you will need to pay"

    It wont happen and isnt practical in all cases, but shouldnt it happen more?

    What if every gas station charged $10 or $12 or $12.75 for a gallon of gas, then when you swiped your card, the actual cost to you was sometimes $6.00 sometimes $3.50 or maybe sometimes even $0! But you dont know until you bought the gas! That's how healthcare operates.

  10. Was it my responsibility to prevent the second ultrasound from being done? Yes. However, if I or any other doctor were to speak out every instance that we witnessed an unnecessary diagnostic test, medication or specialist consultation, we would have scant time remaining to practice medicine.

    I also await an example of anonymous's experience as I found the comment somewhat inscrutable.

    All comments appreciated.

  11. To your comment, Michael, I don't personally find it very difficult to unequivocally recommend against unnecessary services. I usually put it in family terms - "if this were my son or daughter, father or mother, I don't think the likely degree of benefit justifies the aggregate costs and possibility of adverse outcomes … believe me, I'm looking out for your best interests here."

    It doesn't take very long to have this discussion, in most cases. I worry more about being ostracized by patients, referring physicians, and colleagues who don't share a conservative mindset than about having too little time left to practice medicine.

    I occasionally have encountered a patient who is intrigued by the topic of cost and I've explained how it works as follows: most patients are short-sightedly looking to get as much health care as possible for themselves (tests, treatments, referrals, etc.), regardless of the value, since they foolishly assume that more is better. nobody realizes that by behaving like this, they are screwing themselves and everyone else whose premium subsidizes their waste, while everyone else screws them in the same fashion a thousand times over every day.

  12. Don, your gas station analogy is spot-on. Despite the proliferation of mobile devices, I'm still waiting to see any insurers release an app that provides real-time transparency.

  13. @Mark @Michael Kirsch, M.D. Perhaps I’m unlike most when I seek healthcare but I have always asked about cost and care options and offered to pay cash/out of insurance.

    I’ve had 2 surgeries. The first rushed and I cannot recall if I asked all the questions. Detailed billing revealed that saline water was $50 (IIRC). I’m aware that costs are contracted between insurance companies and hospitals but truthfully, I would have been better off negotiating private pay directly for surgical care. I chose a 10k deductible because I can afford to do so but it is a myth that because you personally are a responsible consumer, the process is under your management. Off topic, I find it funny that TV pundits will exclaim the virtues of HAS policies because it will keep costs under control
    My second surgery made me a wiser consumer – I thought:

    I made sure to request those involved be in my insurance network.
    I diligently inquired on both physicians’ fees.
    I consulted with the hospital on their costs.
    IIRC, I paid the deductible in advance for the above services.

    But then…The billing comes. And who is this person who is billing me for assisting in the surgery? Worrisomely, It turns out my insurance won’t pay because he isn’t qualified in what he refers to his position. In fact, I had to tract down though my doctors who he was, what he did and why it was worth 1k (I can’t recall the exact amount). It turns out my Dr.’s reply to my “why someone was billing me under a title my insurance rejected?” inquiry was “he needed his assistance” and that he was a “really good”–kinda scares the hell out of this piece of meat.

    Really, I am aware that physicians are underpaid, insurance equally plays games with your billing but it wasn’t consumers who chose the healthcare through insurance route. I’m aware that physicians practice litigation protection medicine and that’s undoubtedly the consumers fault.

    Patients like me, who study their billing and see a lab test for something that was not needed, nor did require review by another doctor/lab (I cannot recall what) find it so discouraging to have to participate in a game when I just want healthcare.

  14. @Anonymous, you have been held prisoner in the medical billing labyrinth, which is a place were we should place detainees instead of GITMO.

    @Mark, it takes a deft hand to discuss cost control and the patient's best interest in the same conversation. Most folks, I think, would suspect that controlling costs in their personal care is at their expense. In other words, they support cost control on other patients.

  15. @Anonymous, I'm not sure why you previously disagreed with me that "incentives and real-time transparency just aren't there." Your story seems to support the idea that high-deductible insurance policies (which are relatively uncommon) provide an incentive for patients to seek higher-value care, as well as to illustrate how difficult the lack of real-time transparency has made your efforts to behave responsibly as a medical consumer.

    @Michael, with practice it gets easier, and using the right words is important. i emphasize that cost per se is rarely the primary consideration but rather value - almost any intervention that carries a reasonable expectation of providing mgmt-altering information or a net positive outcome that provides meaningful improvement in quality of life generally receives my endorsement. when these criteria aren't met, phrases like "not much bang for your buck" and "more isn't always better" seem to resonate with patients. it's convenient to rest in the presumption that patients (and their families) won't understand and/or acquiesce, providing us with "cover" to carry on with business (and reimbursement) as usual. it would be helpful for patients to SEE the savings that are realized by a more conservative approach to care.

  16. I hear your point, Mark. I think it might be more palatable for patients to advise against unnecessary medical testing because they are not needed and won't affect clinical management than to couple this with a cost-control argument. Why discuss the cost when we can win the argument on the merits? I think the public needs to be engaged in the cost-control conversation. I'm not sure this should occur in an exam room with respect to an individual patient's care.

  17. Discussing necessity is a reasonable starting point. The problem is that relatively few interventions are *clearly* needed or not needed. Most decisions occur in a gray zone, and they come down to patient and/or clinician preference/desire. At these moments, who is looking out for the payer's interests? When an insured patient replies to your argument that a particular intervention isn't necessary by saying, "But it won't hurt, will it? And it might help, right?", an explicit consideration of value is worthwhile, on behalf of everyone whose premium is going to go up a little bit because of this decision.

  18. @ Mark, I'm a bit confused myself on your question but my point is that the control oriented consumer is still left out of the decision loop.

    HSAs and self-owned products do incentive consumers to seek cost-effective healthcare because unused funds were eligible for a future a retirement account but the care cost-control application is a failure because it is based on the established model.

    HSA healthcare isn't an A to B approach that pundits and the inexperienced typically portray. IOW, the HSA type product market share is limited to an educated consumer, who still will likely learn docimastically.

    First, “self-insurance” is a misnomer in that the HSAs require a high-deductible policy that employs the same billing/approval negotiated between insurers/providers process as the common product. Therein lies the rub: incentives and real-time transparency just aren't there because healthcare is a business transaction and the consumer isn’t a partner in the negotiated payment schedule of goods and services, nor can you opt-out of said contracts and make your own deal. For example, hospitals offer consumers elective surgery goods and services at remarkably reduced rates because they feel the heat from surgery centers

    HSAs could have been the common if they were as simple and the insured was its director. It should have been a contract between the consumer and their doctor/hospital/medical device provider. Few consumers would waste their time and money trying to reach a 10k or 20k deductible just to get something for free and the simplicity of direct patient billing would permit a physician to specialize in medicine, not billing codes.

  19. @Anon, I think we are in full agreement on the essence of the market failures in health care. can you explain what you mean by "learning docimastically"?

    thank you for doing your part to be part of the solution in this mess. hopefully you will be able to find like-minded health-care providers for your future needs.

  20. @Mark Learning docimastically: HSAs involve paperwork that includes establishing a specialized HSA-qualified bank account with rules to follow; establishing HSA- qualified (HDHP) medical insurance (very little choice) with rules to follow and IIRC, I had to often explain what it was to front offices on doctor visits and the rules they needed to follow! Further, HSAs are treated differently for tax purposes with rules to follow (Form 8889) –I eventually dropped it for a high-deductible traditional insurance policy which I’m ashamed to say I haven’t used in years because I’ve become negligent in my own care.

    The complexity of why we have market failure and how we can circumvent the problems is way too long for a blog reply!