Sunday, December 7, 2014

Should Your Doctor Consider Medical Costs?

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?


  1. In 2013, Medicare recipients got most of their drugs at no cost above the Part D prescription program, but this year, that benefit was removed from us so many thousands of seniors stopped taking some or all of their meds. That results in many more hospitalizations - Medicare + supplementary insurance paid for totally - then the cycle begins. Or the patient dies. It was cheaper to keep them healthy than to hospitalize them, but there goes the wisdom of the federal government. I myself pay for a supplement to my traditional Medicare plan so I can have the very best physicians and tests and hospital stays, but I can't afford the $88 per month deductible for the eye drops that will greatly slow my impending blindness. I told my doctor that, and he just shrugged his shoulders. Social Security has not kept up anywhere near the inflation rate, giving us a raise of 1 or 1.5% when groceries have gone up 56% and gasoline has tripled, along with a greatly increased electric rate. My husband had a heart attack and triple bypass this year, and needs new drugs so I quit taking most of mine. Please tell me that there is a plan to do better with Medicare and a plan to rid my kids of Obamacare, and tell me why the doctors here are driving Porsches and Lamborghinis. One doc locally collected $18 million in one year for doing unnecessary tests for Medicare patients! There's a lot wrong with our system, and in so many ways. So much is wasted that could do so much good if better utilized. In light of the impending blindness, I just elected to let nature take its course and have chosen quality of life over recently recommended surgery and the drugs that would follow because of the costs that I cannot cover. Too many would choose the surgery and not follow up with the drugs because of cost. Medication costs in the US are far, far higher than for the same drugs in other countries. It is time to stop that. Yes, our doctors do have to consider costs, see if there is a less expensive option, and too often they don't even know the cost of what they prescribe.

  2. I think it depends on the individual pt. Someone who is still 'with it' and can lead a decent life v. pts with dementia or too many other ailments. My GP was always good about considering cost, but w/o insurance, my last visit went like this:
    Me: I'd like a test for x
    Her: You can't afford it
    Me: How about blood work?
    Her: You can't afford it
    Me: Such & Such prescription
    Her: I'll write it, but you
    can't afford it. Do you know it's been 3 years since I saw you?
    Me: I can't afford it.

  3. "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? "

    Uh no. You treat your patient and the illness they have. You don't penalize them for economic inefficiencies that make their medications/treatments more expensive. The price tag isn't their fault.

    I don't see it being the doctor's role to bring global concerns to the care of an individual patient. Those are broader policy issues where the solution isn't going to be found w/i one individual. And costs are driven primarily by politics, hospitals and pharmaceutical companies. Yes patients seek care, maybe too much care, but they can't be held liable with their health as if the other factors are blameless.

    Where patients do need help is making wise decisions about what to spend their money on and physicians who will work with them to stretch their dollar when insurance isn't enough. The problem is the standards-of-care were established as if there was no end to the money and are the gold standard for avoiding accusations of malpractice. So now physicians who try to tailor care to limited budgets open themselves up to additional legal risks.

    So they won't be able to help the patients. Well, at least I guess more patients will die from lack of care due to lack of funds and shitty ACA insurance, so that will reduce the burden on the system somewhat.

    The system is broken.

  4. The system is very broken, and we need ALL our doctors to insist that Congress undo the ACA and guide us all into a new era of exceptionalism. Many of us (yes, I started our city's tea party because of Obamacare, 1 month after he was elected the first time) tried to stop it, but we didn't have enough help from the medical community.

  5. Very enlightening comments all. When I see a patient, I am thinking only of that patient's interest, not society's interest. But, I do think a strong ethical case can be made that physicians need to think about the community at large in their deliberations.

  6. We should all consider the costs both to the individual patients and to society at large. I am outraged at what I see in the office. Tests that have no bearing on the treatment. Sometimes CT's a day apart, in kids no less. Not taking the time to look things up-just send a consult. We have so much at our fingertips to develop a plan. Just Dump on someone else to take care of the patient. Some of this is the result of shift work in medicine-not taking personal responsibility for each patient. You do things pretty cheap if you
    1. take a good history
    2. do a good physical
    3. get to know the patient's social situation-
    saves lots of money in consults, tests and referrals.

    The system incents the wrong things. The "quality measures" in my system are a joke. I can't believe the poor care I see in the charts yet the providers are "meeting their quality measures". It is crazy.