Tuesday, April 13, 2010

The cost-conscious physician: an oxymoron?

Several years ago, when my wife directed the third-year Family Medicine clinical clerkship at a highly ranked medical school, she developed a popular workshop on the cost of health care that presented students with scenarios of patients who were either uninsured or underinsured and challenged them to provide cost-conscious health care by selecting medications and tests that were clinically appropriate and financially affordable. Many students remarked that it was the only time during their two years of clinical rotations when they were required to consider costs in decision-making.

Now that the U.S. health reform bill is law, and over 95 percent of Americans (as opposed to today's 84 percent) are expected to have health insurance by 2014, many physicians may be tempted to think that they can ignore the costs associated with prevention, diagnosis, and management of patients' health conditions and just focus on doing what's "right" for the patient, since somebody else is footing the bill. But contrary to popular opinion, that "somebody else" isn't an insurance company or the government; ultimately, it's the patient, in the form of higher insurance premiums (or taxes) to pay for an ever-expanding range of tests or treatments of questionable or zero benefit.

In response to Dr. Howard Brody's challenge to the medical profession to identify lists of unnecessary tests and treatments, physicians have suggested antibiotics for colds, coronary calcium scans, PSA and thyroid tests in well patients, drugs for high blood pressure that are more expensive and offer fewer benefits than older drugs, MRIs and spinal fusions for low back pain. If it's so easy to come up with a list, then why is it so hard to eliminate the waste? According to a recent Newsweek article, the problem is that many of the items on the list are physicians' financial "bread and butter." "We doctors are extremely good at rationalizing," says Brody in the article. "Somehow we manage to figure out how the very best care just happens to be the care that brings us the most money." Other concerns voiced by physicians are that patients have come to expect (if not demand) much of the aforementioned unnecessary care because it's been going on for so long.

But if health care reform is to have any hope of slowing the extraordinary growth in the cost of health care in the U.S., doctors can't keep looking to patients, hospitals, pharmaceutical and medical device companies, and insurers for solutions. In an editorial in the New England Journal of Medicine, Dr. Molly Cooke argues convincingly that cost-consciousness must be systematically incorporated into medical and continuing education:

First, we should be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care.

"Value" isn't about saving money, but means getting the maximum health benefit for our enormous investments in health care. This wake-up call needs to be delivered and reinforced to students, residents, and health professionals at every level - starting today.


  1. How about bimanual exams in asymptomatic women?

  2. I recently posted on this subject in a post picked up by KevinMD. I like your blog, and as a fellow family physician find trying to provide good care, control costs, and not ignore the need to remenber to practice CYA medicine quite a challenge


  3. So, when you shop for food, does the store manager tell you what to buy and when to stop or you make a budget and stick to it ?
    The artificial idea that doctors have to police cost is very dangerous and it will not work. It did not work with the HMOs. Plus, many times it is unethical : if you provide incentives to doctors to control cost, it may interfere with best patient care. The same guys who make money now by convincing you that the coronary score helps, will be the guys convincing you that you don't really need an endoscopy right away for that 4 months old epigastric pain. The same people who milk the system now, will find a clever way to milk the system later.
    On the other hand, if you do not provide any incentives to doctors to control cost, why would they even bother ? Let's say that you "punish" them somehow for not staying "cheap". In 10 years there will be very few people left to punish. People change behavior but not the way politicians think. And physicians are not some sort of morally superior bunch, they are a mix, like the rest of the population.

  4. I agree that we need to provide more incentives (carrots, not sticks) for physicians to practice appropriate care. To use your grocery store analogy, I wouldn't tell the customer what to buy, necessarily, but would put things on sale. I'll be publishing a guest post later today about encouraging patients to seek preventive rather than reactive care.

    However, most people assume that costly services are better, which is rarely the case. Primary care docs prescribe lots of high-priced new brand-name medications for high blood pressure that are no more effective (and often less effective) than a generic diuretic drug. We rushed to switch patients on Celebrex and Vioxx when it was no better than ibuprofen and led to thousands of heart attacks. We switched patients from generic metformin and sulfonylureas to Avandia for diabetes, which resulted in thousands of excess cases of heart failure. Pharmaceutical companies deserve some of the blame for deceptive advertising practices, but ultimately it's a doctor's choice whether or not to prescribe an untested, costly medication rather than a "cheap" one with a long safety track record. I'd argue that in most cases, we can have our cake and eat it too.

  5. Hi Dr. Lin,
    Love your blog. I agree with Dr. Cooke, "that cost-consciousness must be systematically incorporated into medical and continuing education". But there are so many factors that influence a doctor's decision on ordering a certain test or procedure: a patient's insistence on a certain test, a doctor's belief in doing certain tests and the fear of malpractice, to name a few. I am so glad that there is this dialogue happening among the medical profession. As a nurse and consumer of our health care system, I believe that is a big step in developing a cost-efficient system that works well for the doctor and the patient.

  6. Thanks for the nice notice re my NEJM piece and good luck with your new projects.

    Molly Cooke

  7. America's doctors should adjust their clinical practices to accommodate economic considerations.