This wonderful article from Atul Gawande does service through example. Rather than talk about costs in abstract, he tells an important story – The Cost Conundrum
Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars. I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago? Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill. And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization. “Oh, she’s definitely getting a cath,” the internist said, laughing grimly.
This story tells of the incentives that drive procedures and testing. Dr. Gawande gives a great contrast – the Mayo Clinic.
If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.
Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.
Why do we have this variation? I believe that money has too much influence on physician decision making. Now I will admit that I have always received a salary, being an academic. I have no incentive to keep patients an extra, see patients too often, or refer to a testing center that I partially own. Many would argue, and I would probably agree, that we should take financial incentives out of the physician decision making process. These conflicts likely cause our cost problem.
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Playing Devil’s Advocate here… what are the incentives for better healthcare if we adopt a salaried system? Pay less and get less. (gosh, I feel like Happy Hospitalist saying this.)
Is there a huge difference between standard of care and excellence of care? I would like to think that the only difference is the perception of minimal benefit with some increases in cost.
Canada and the US VA system are places with salaried physicians. Patients have to wait weeks for care in both systems. The doctors have the benefits of paid vacation, retirement plans, and limited hours. A Canadian physician told me that once he sees his monthly quota of patients, he does not have to see any more.
Many of my patients have me for their main primary care doctor but go to the VA for “free” blood tests, x rays, and studies. Medications for 90 day supplies at the VA are around $9, including for many expensive brand names. The reason the patients see me, is that there is no nearby VA hospital in my state, and a neighboring state has the VA system about an hour away. I end up being the admitting doctor for these patients to my local hospitals and being the doctor who is available after hours and on holidays. The VA and Canadian doctors have no incentive to see more or less than the required patients.
A positive note about the VA nurse practitioners and doctors is that they are very good with preventive medicine and ordering lots of labs, including ones that would be denied by many private insurance companies. A negative factor is that Canadians and VA patients seek care from private doctors in the US when they want something done quickly, instead of waiting a month for an MRI or a week for a CXR.
The downside of being salaried, such as academic physicians or ones who work for nonprofit organizations, is having to be an employee with nonphysician bosses. As an independent doctor, I set my own hours, my own number of patients seen each day, and my choice of patients. I have a high quality group of patients, who have selected me for their care. I don’t think I would enjoy medicine as much if it were a 9-5 salaried job.
Part of the difficulties with US medicine is that the combination of liability and family attitudes make us spend thousands of dollars for the last 1-2 weeks of life in patients without providing any higher quality of life. Somehow encouraging hospice or other alternatives to ICU stays for 90 year nursing home patients with recurrent strokes/MIs/dehydration does not seem like the best use of health care dollars, when these same patients do not have quality living and often are in the end stages of dementia.
Is Centor’s patient population the same at UAB as in central Illinois or central Georgia? Do patients come to academic centers already having had their tests, in which case Centor does not need to re-order them? Do patients in academic centers have 24/7 coverage so that there is always a clinical eye to see that patient? Some tests might be done in lieu of constant follow-up. You don’t send folks back to the farm 25 miles away with questions perhaps answered by Bayes’ Theorem because the stakes might just be different. Has Centor already stated by his choice of career that he seeks the perfect diagnosis rather than the adequate diagnosis? Many times one does a test to rule out the worst possibility in a perhaps chaotic family situation. Money likely does influence health care decisions, but BOTH ways, no? Isn’t some care denied for money? Is it more or less than potential physician abuse? Is some putative abuse really the result of lousy physician documentation? We sometimes do a test without writing down our thought processes or the diagnoses that establish medical necessity. By definition, then, you have “an unnecessary test”. Do you have a testing center “partially owned” by doctors because nobody else wanted to make that technology available? Or perhaps because the hospital testing center stinks? Or takes too much time to get results back?
Do we even ever define “medical care” as opposed to “health care”? Do we define it from an “illness”, or patient-, perspective, or from a “disease”, or efficiency-, perspective? Do we mix the language of each? And so draw invalid conclusions?
Did Centor make a career choice based on dollars? Well, he likely has zero overhead, 4 weeks of vacation, no malpractice insurance, a secretary, a coder, a decent parking spot, CME paid per contract, job security, ready-made social authority and respect. Plus a pension, I think. Let’s say he brings in $150K/year. What would you have to book and collect to get that in, say, rural Alabama? Your overhead is likely approaching 60%; let’s make it 55%. Your collection rate is maybe 90%. Medicaid, no insurance? Have to add it in. So if you book $600K, you’d end up with about $150K. If your average patient is a 99213, that’s about $50/patient. You’d have to have 12,000 patient contacts/year. Make it 9,000 because you’ll have some 99214′s (which the insurer didn’t downcode), consults, tests (EKGs). If you take 4 weeks vacation, you have to see about 190 patients/week. About 40/day. In 8 hours,…you get the picture. No time for a nap. Dr Centor might have made not just the right decision from an altruistic perspective, but from a financial perspective as well.
I intend no disrespect. I am not trying to be rude. All I’m saying is, this is no time to lump; splitting is the only way to be ethical. Let’s be certain about every patient who appears to have had a decision made about her medical care on a financial basis. Let us calculate the benefits of each position, recognizing that decisions are often made NOT on a rational basis, but on a social or psychological basis.
Gross calculations are indeed…well…gross. Let the IOM come to central GA or northern AL or rural OK, live there, practice there, raise children there, see their patients in the WalMart. Let the local family doc’s, and the occasional rural neurologist, be magically transformed into judge and jury after a suitable number of years, our children having gone to the college of their choice, our IRA’s fully funded. Then let’s all meet at the Cafe South or the Waffle Hut or wherever the Rotary just finished up at, and close the doors, and look at each other, and with respect and admiration, ask, “Good Lord! How the hell did you do it?”
Dr. Centor, do you not see the paradox in subscribing to the Dartmouth school of thought on spending variations at the same time you’re lambasting the idea of measuring quality of care?
If you don’t have some conception of quality that can be measured, then you have no empirical grounding for any criticism of overspending.
I suspect, in your heart of hearts, that you know quality can and should be measured. You think about what happens to patients. That is good. If you didn’t do think about whether patients benefit from the care we provide, you’d have no way to fairly compare high- and low-spending provider communities. But as I’ve said before, I’m not sure what you get out of your straw-man arguments against quality measurement in health care. You can’t have the Baicker/Chandra study (or any other Dartmouth study using a quality metric) without quality metrics.
I am Navy trained in Medicine and GI. I’m now in solo private practice in a small New England town, and the only GI in my county. I own an endoscopy center, so I have every incentive to sling more scopes, and I sure need to, because 10 years in the Navy doesn’t make you rich and I have 5 kids.
Can’t speak for the culture in Army or Air Force medical, but I was brought up to judge the indications for a procedure on clinical grounds alone- irrespective of cost, but also irrespective of personal profit. That mindset has stayed with me. It’s quite common for PCPs to refer people for endoscopy when what they really need is some thinking about the case. I get in arguments with patients who think I’m being lazy or greedy (huh?) when I tell them they don’t need a procedure. Of course, I also get in peeing contests with insurers who, having of course only the patient’s best interests at heart, tell me the procedure is not indicated.
I think many of the unnecessary referrals for procedures and subspecialist consultation arise from the phenomenon described above by Dr. Block: spending 30 minutes figuring it out yourself actually costs you money if you’re a PCP.
I was an Internist for the Navy for four years, in places where subspecialty care was not available. I learned to figure it out myself, and that was while seeing 25 patients a day. But I didn’t have an insurer breathing down my neck. And I didn’t lose money if I spent more time.
So yes, the culture makes a big difference. I’ve been shocked at how many patients, having moved here from elsewhere, were getting followup colonoscopy every 2 years after having a hyperplastic polyp. Ya gotta wonder.
And Dr. Block is certianly right about the region: here we take care of it, because there isn’t anyone else nearby. I’m the only subspecialist in town. Gross numbers are deceiving. Numbers like “47 million uninsured”.
I think the take-home message is that doctors are economically rational, legally prudent, and products of their environment. The private insurance industry and Medicare are dysfunctional systems that don’t reward outcomes, don’t reward efficiency, and don’t reward skill. Meanwhile, the current tort system scares doctors into practicing excessively expensive, specialist-happy, massive test-ordering, no-evidence based medicine.
The onus shouldn’t placed solely — or even mostly — on doctors. It’s the practice environment, stupid.
To quote a different Dartmouth professor not Elliot Fischer:
“Every system is perfectly designed to get the results it gets.” -Paul Batalden.
To change the way doctors practice and the way people receive health care, we need to revamp everything top to bottom.
-MW
As far as costs are concerned we also have to consider control over bargaining power. When HMO’s were established, it was a key moment for these organization to utilize their influence to control for costs. However, as Maggie Mahar in her book “Money-Driven Medicine” points out, the opposite happened; costs were negotiated for the provider and not for the patient. This lead to services being cut to cut costs for the provider, leaving the patient with no choice.
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