How do we achieve high value cost conscious care?

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Category : Medical Rants

The NY Times has an important and provocative piece – Overtreatment Is Taking a Harmful Toll

The title is a bit misleading.  The article focuses more on over testing.  We test too much and we treat too much.

The article, while mostly accurate, does not really explain the reasons for the problem  Unless we can accept and understand the underlying reasons for these problems, we cannot successful correct these problems.

Let me suggests the major reasons for over treatment and over testing and then address them over the next couple of weeks.  Prior to writing about each one, I do want to see if readers can suggest any more or disagree with the list.

  1. Our payment system – that pays for each thing (i.e., diagnostic tests, visits) encouraging us to do more things.  We get paid the same when we spend less time with the patient and order more tests. 
  2. Advances in technology – we have better imaging and more laboratory tests.  Sometimes the tests are too good, and suggest that we do more tests.  Perhaps we should do more careful history and physical exams and do less testing.
  3. Guidelines based on single diseases. We use too many medications to achieve targets that may help a disease but hurt other diseases.  Too often we have guidelines that do not give us enough "leeway" to individualize therapy.
  4. Patient demand – patients think they need an MRI of the head, because a friend said so.  That friend knows someone whose 2nd cousin had a rare brain tumor found because of an MRI, thus you must get an MRI.
  5. Malpractice fears – studies never document this, but all physician know that it is true.  This is especially true in emergency departments.  Every time I write this my comments fill up with emergency physicians justifying all the studies they do.  But ask any hospitalist about excess CTs in the ED.  The first abdominal CT for cryptic severe pain makes sense.  Perhaps the second, but certainly not the 5th, 6th and 7th.
  6. Marketing from big pharma – leads to more expensive drugs and increased patient demand for those drugs.  This occurs especially from direct to consumer advertising.
  7. Lack of information from other physicians – our obsession with privacy and HIPAA decreases the sharing of important medical information across sites.  Every time a patient sees another physician the order the same tests – easier than trying to get the old results.

I am certain that I have not been totally inclusive in my list.  This is really a multi-faceted problem.  Please add your thoughts.

Comments (9)

Spot on in every particular.  Numbers 3 and 7 are lesser known (and lesser discussed) than the others, though I would argue it's more laziness than HIPAA per se driving a lot of investigative duplication. 
Fixing it is equally complex, though. 

Understanding of disease processes and natural history of disease/ clinical illness. Because these days training is not of the same quality; whatever I know today is due to a handful of teachers- these guys were all excellent clinicians but not superstar researchers. All superstar researchers I came accross had their own biases.

No skin in the game.  We can order as many negative pan CTs and MRI's as we want "just in case" without any economic accountability as to their cost to the system.  Also, what I perceive to be frequent and implicit overvaluation of throughput skills in residency training (navigating the system quickly by expediting tests and consults).  Finally, "quality improvement measures" that emphasize thoughput such as at my centre linking hospital payments to shortened ER wait times – increased time pressure causing less time for bedside assessment and to make up the difference more and quicker consults and more testing- paradoxically can cause increased wait times and more testing!

Actually, I think #7 has been talked about quite a bit (remember, that was how EMRs were going to save billions on a daily basis) and is really not that significant. With a well-trained staff, necessary outside information is available 99.9% of the time. Testing is repeated  even when old records are available because the patient's condition has changed, the previous testing raised some questions, or (mainly) there are bucks to be made on repeating it. Send a non-Medicare patient with complete records to M*** or Cl******* for an elective work-up and watch everything get repeated, maybe two or three times.
If we think we're spending too much on CTs, MRIs, etc, yes we should reduce the number that we're doing, but it would be much more effective just to pay less per test. If Medicare paid for MRIs like they do for E&M codes (at overhead minus 10%), watch what would happen . . .
 

How about adding patient knowledge?
 
I can list many a patient who can't tell me what has been done in the past or where she had the testing done or even what disease she has been diagnosed as having by a previous doctor. Very frustrating from my POV. And so I need to do a work-up (can't treat without knowing WHAT I'm treating).

How about adding insurance restrictions that end up actually adding costs. Take a 45 yo who is generally healthy, but both parents died in their 40s from MIs. The patient is extremely anxious about their CV risk.
 
The patient comes to the ER 3 times over a year with chest pain and anxiety and has stress tests done each time – normal. Insurance will not approve a cath and does not pay for a coronary CT. How many times does the patient need to be readmitted and get another stress test when a cath would likely give a definitive answer and could help ease their anxiety?

I can think of a few more reasons:
I think there is sometimes a fear of embarrassment. Like a consultant will tell the patient "your idiot internist didn't rule out porphyria" or some other obscure disease so we may err on the side of ordering things
I also think we like to break up the monotony of our regular routine of managing DM and HTN and COPD by trying to find a zebra. It makes things more exciting if our 10th patient of the day with uncontrolled BP has a pheo rather than just not taking his or  medications.
I often take the if I don't someone else will approach. Even though I don't think the patient with headache needs a CT scan I may order one just so they don't end up calling a neurologist to get one who will instead end up ordering an MRI/MRA, EEG and transcranial dopplers. Besides at least the results will come to me and I can decide if I really need to get the 5 other studies recommended by the radiologist to further evaluate incidental findings before the consultant orders them.

A lot of health care is about ownership and not wanting to give up our patients and their information to the competitor.  You would think with EMRs everywhere that we could get access to the xray and ekg done last week in San Diego when the patient shows up in the ER in Palo Alto the following week.  Sounds way too reasonable.  Enjoy your blog… it's very reasonable.

training that emphasizes chasing down zebras instead of effeciently managing the 99%.  (hope that doesn't hit a nerve)
P4P and measurement that result in overdiagnosing, overtesting, and overemphasizing any benefit the patient may get from an intervention.  All so the "quality scores" of the physician look good. 
 

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