Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.
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.So, in cases where the science is unclear, doctors in high-cost cities tended to adopt a "more treatment is better" approach. He points out that this can't all be explained by differences in the doctors' training. In any given city, doctors come from many different medical schools. He argues instead that, sometimes, a culture of over-treatment arises in some cities. And, sometimes, that culture arises because some doctors develop an entrepreneurial spirit about the practice of medicine. Health care costs are explained, then, by some mixture of hazy science combined and the particular culture of medicine in some cities. It's the culture, then, not simply individually greedy doctors.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.
What this suggests is that better science can help us reduce costs. For this reason, I think the Democrats are wise to push "comparative effectiveness research" and the Republicans wrong to oppose it (the Republican strategy appears to be to stringently oppose reforms that would save money in medical practice, and then bitterly complain that health care reform is too expensive).
3 comments:
This is Bryan responding. I completely agree. That summarizes perfectly, what I was trying to explain about over-evaluation. it happens all too often. Just because the test is available does not mean it needs to be ordered. The physical exam, that was so much a part of the art of medicine (not to mention way cheaper) has been lost to expensive diagnostic testing. It is truly a shame.
Hey Bryan, Kyle here again. I read the article and it was a great read. It was very well written and addressed many of the questions that arose from your initial post and then some. I did have a few issues/questions remaining.
The part in the article where Gawande is talking about how the risks of procedures many times outweighs the potential benefits left me unsettled. He says "some hundred thousand people die each year from complications of surgery" arguing that generally most of these surgeries shouldn't have happened in the first place. Most of the time there isn't much of a choice. I heard that hip fractures and bone breaks are one of the leading causes of death in the elderly. They don't die from the actual break, but from the surgery to fix the break. My great grandmother died this way, the doctor had our family pretty much say goodbye before the surgery. But what choice did the doctor have? When you are facing surgery you are weighing a bad option against a worse option and to say we are over operating in this country is hard to prove.
He spent another paragraph discrediting a high deductible model of health insurance in the wrong way I believe. I don't believe that high deductible insurance is a cure all, but it would incorporate more market forces than the way he portrayed it. He said it wouldn't help anything because patients aren't going to barter with their physician which is true. But patients could compare pricing from one hospital to the next, the 'bartering' would happen outside of the office when choosing where the procedure is done. And patients are most times willing to travel sometimes great distances to save a buck.
Monica is currently being seen by an endocrinologist who is much more aggressive than what we have experienced in the past. Especially during Monica's pregnancy with Sofia. He had her blood tested every month where with Aiden (in Utah) she had it tested twice the whole pregnancy. Aiden and Sofia both turned out fine, but I don't mind letting the doctor have some leeway and freedom to practice the way he wants. So where do you draw the line? It would be interesting to know if our doctor owned the lab that she goes to get her blood drawn.
I would be interested to know what doctors out there think of working at a hospital on a fixed salary. It seems like a pretty good idea to me and would like to hear arguments against it (which I am assuming would come from medical professional if anywhere).
Here is what I don't like about government sponsored comparative effectiveness research. It is not the research itself that bothers me or I presume the Republican Party. It is who is sponsoring it and what they are going to do with the results of the research. And they are planning on doing something with the results, or what's the point. I would feel much more comfortable with the AMA sponsoring such an organization (and to some extent they already do by examining research and making recommendations for some treatments). The government dictating medical treatment, even when it's based on current research, is where you will run into opposition. It seems as though this comparative effectiveness research is a step in that direction.
Kyle -- an excellent set of detailed questions and comments here.
About physicians accepting salary positions, I suppose the answer would be "depends on the salary." I can imagine that not having to worry about the particulars of patient payment, though, may be an attractive thing in itself.
I think the high deductible model might be an effective way to reduce cost. But it seems to go against my view of the place of healthcare in human life. If my daughter Nora gets hurt, I don't want to have to make decisions about going to the emergency room based on cost. When my daughter is hurt, I am not a rational actor anymore and it is unfair to ask me to be. Buying health care is not like buying a plasma TV. Plus, such a model would probably prevent many people from going to the doctor until it was really late, thus making their care more expensive overall. So, those are the reasons why I personally don't prefer that model.
With regard to comparative effectiveness, presumably the research would follow how other government-sponsored research typically works. That is, the government would sponsor the research in the form of grants, but the research itself would be selected and undertaken by outside researchers going through the peer-review process. The AMA and other groups could then make recommendations based on this research.
I don't think anyone is proposing to use such research to prevent people from buying procedures deemed "ineffective." But people and taxpayers have a right to know whether the care they are paying for is effective. If a patient wants to pay for a treatment, more power to them. But the taxpayers (through medicare and medicaid) shouldn't be paying for treatments that can be shown not to work. This could reduce health care costs overall, and help the long term federal budget. It is rationing care, but only care that doesn't work.
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