Thursday, March 8, 2012

Excessive Use of "Health Care"

Ask almost any doctor or nurse, and they can tell stories about mess-ups in health care. Sometimes, it's under utilization, sometimes the wrong treatment or test is done, and sometimes it's inappropriate overuse of tests or treatments.

I was discussing this with an ophthalmologist recently. He had been working for a large medical group with a business office concerned about high overhead costs and the "inadequate" revenue from the expensive equipment. The 11 ophthalmologists were told directly by a VP administrator that they weren't billing enough and thus they weren't meeting their targeted revenues. They doctors countered that they were providing appropriate and high quality care for their patients. The administrator countered, "Listen, if you have a patient in the office and there's a billable procedure, DO IT"!

Six of the doctors rebelled and subsequently left this group, after making their position clear that they wanted to practice within both legal and ethical boundaries - and could no longer do so in the cost/procedure driven environment.

When I was scouting around for my first job in internal medicine, a group of doctors asked me if I was interested in becoming their "thyroid guy". They had just purchased a thyroid scanner and felt they had a golden opportunity to generate a high revenue stream from Medicare and insurance billing. They were also doing routine viral cultures on sore throats (not at all worthwhile) to generate revenue. I didn't say it directly to them, but why did they exploit the potential to overuse diagnostic procedures? Did they derail their idealism somewhere in training?

Amazingly there is very little documentation about unnecessary testing and treatment. Recently the Archives of Internal Medicine reported a study in which the authors researched the entirety of 21 years of medical literature evaluating 114,831 publications. They found only 172 articles with data on health care overuse—and most were devoted to either overusing antibiotics for upper respiratory infections, or three cardiovascular procedures.

It is estimated that 30% of health care costs are unnecessary, but how do we arrive at reliable information about overuse? Even more difficult, how do we change behaviors? All of us have ideas such as changing incentives, tort reform, more evidence based research, expert opinion guidelines, more primary care teams, etc. Unfortunately the current proposals for health care reform don't effectively attempt to deal with overuse of scarce and expensive resources. But the end of double digit health care cost escalation will come, like it or not. Let's hope the public discourse can be rational, not "don't let the government mess with my Medicare!"

It's quite likely that end-of-life care is unnecessarily costly, both in suffering and dollars. There is wide variation in hospice use and dying in the hospital from city to city. Such wide variation demonstrates how much improvement in care is possible.

PS: Having my own health coverage under Medicare now, I do appreciate this nationwide (gasp) socialized medicine. It is too costly at present, but if we can be successful in dealing with overuse, this will correct dramatically.


  1. It's reimbursement driven. You spend half an hour reassuring ancient Mrs. Goldstein that she can live a good life with her macular degeneration or you send her for whatever imaging can be done. Lots more money in the latter. And much poorer care. I keep cracking up at hospitals cutting nurse/patient ratios and then expecting improved Press Gainey scores because they implemented hourly rounding. With all of our devices the most healing part of the medical paradigm is human caring *coupled with* prudent use of dagnostic equipment and medication. And how can one be prudent if one can't take the time t listen to the patient?

  2. Very good point. Time with face to face contact in a non-rushed fashion seems to be rapidly fading as we add patient numbers, charting demands, and very sick complex patients in the hospital setting. Even in the clinic for 15 minutes the other day in California with a family member, I found the doctor spent 80% of the time in front of the computer reviewing and typing in information, 5% of the time gathering new information, 5% of the time doing a remarkable cursory exam, and 10% reviewing the three meds he was prescribing.

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