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Recently in the Times‘ “Patient Money” column, Lesley Alderman shared nine physicians’ views on how we might reduce our country’s health care mega-bill.

Here, I’ll review those comments, add my two cents to each, and then offer my suggestion (#10, last but not least)  regarding how I think we might reduce health medical costs in North America without compromising the quality of care doctors might provide.

The “answers” from the Times piece*:

1. Insure Catastrophes Only

I don’t see this as a solution, first because it would reduce insurance costs without reducing routine health care costs. This sort of system would discourage people from seeking preventive or routine care. And it might effectively punish those with non-catastrophic illnesses.

2. Change Malpractice Law

Yes, fear of malpractice triggers some extra medical testing, driving up costs, hassle and occasional risks. But I doubt the costs of malpractice fear-inspired medical testing amount to more than two percent of our health care budget, if that much.

This point is valid but is way over-emphasized by the AMA and others.

3. Counsel Nutrition

It’s hard to argue with your mom. (Eat your fruits and vegetables.)

This falls into the category of preventive care and better public education and is obviously a good idea. But given the anticipated physician shortage, I’m not sure we can afford for many doctors to spend a lot of time on this topic. Ultimately, this agenda may be best served by nutritionists who collaborate with physicians, schools, public health programs and other agencies.

4. Rely on Evidence…

I agree. But the evidence has to be fair, current and free of bias, including academic bias.

5. But Allow for Expertise

Yes.

6. Use ‘Integrative Medicine’

I’m open to acupuncture, herbs and other “alternative” remedies if people find them to be helpful, and even more so if there’s evidence to support their use. At the same time, I’m wary – there’s a huge amount for sale in this market.

As far as reducing health care costs, I doubt that more integrative medicine would be effective. I’m not persuaded by the evidence supporting hypnosis before surgery, as is mentioned in the Times piece. (And just in case it comes up, somewhere else  – I don’t think the purchase or use of candles has anything to do with health care in the absence of an electric black-out.)

7. Pay to Treat Child Obesity

Sure, someone should intervene to help heavy kids slim down before they become heavier adults. But it’s better to reduce obesity before it happens. (Back to the garden, suggestion #3, above).

8. Stop Over-treating

This huge idea, articulated by Dr. H. Gilbert Welch, is essential to reducing health care costs.

The problem is in establishing a consensus on what’s worth screening for, what’s worth treating, and what’s best left alone.

More on this later -

9. Restore the Humanity

“…There are doctors in training now who do not want to do a physical exam; they just want the lab tests and the echo-cardiogram on a heart patient, for example. But the laying on of hands is a powerful tool in establishing trust and in healing…”

The idea here, provided by Dr. Edward Hallowell, is that doctors order tests rather than knowing and examining their patients.

I couldn’t agree more completely.

*For the names of the physicians who were quoted in the New York Times, please check that column directly. (As I’ve excerpted from their comments, that were already condensed, I don’t think it appropriate to use their names out of context here.)

So, here’s my entry – if I’d been asked by the Times columnist what I think should be done to reduce health care costs, I’d say something like this:

(10) Think More, Do Less

For a swamped, chronically-running late physician (know a few?) it’s easy to order a standard set of tests (such as blood work, an electrocardiogram, a urine analysis and sometimes even a CT scan or MRI) before meeting a patient. So a doctor working in a hospital might wait for the labs before evaluating a patient in the emergency room. In an office, a consulting doctor might “lab” a person (yes, it’s been used as a verb) before thinking about the case.

Lately, patients are speaking up a bit in this regard, partly afraid of x-rays and partly afraid of the costs of so much testing. But, especially for hospitalized patients who are sometimes quite sick and may not be able to say no, or “doctor, do I really need that test?” most rely on their physicians to weigh the costs and potential benefits of what tests they order and treatments they prescribe. (This ties in with point #8, above.)

Stabs at efficiency like admission “order sets” for hospitalized patients can be useful in busy hospitals and may, indeed, render it less likely that a needed test is left out when blood is drawn. But for patients who are hospitalized for, say, two or three weeks at a time, with multiple tubes of blood removed each day, the tests add up. (Note:  some very sick patients do indeed need lots of blood tests, sometimes as often as every few hours.)

What I’m suggesting is that doctors shouldn’t order tests by default, in a routine sort of way. Excessive, daily blood work in hospitalized patients is just one example of this phenomenon. I’m aware of other, costlier examples.

Ultimately, what I think would help patients most, and would save lots of money, are smart and well-educated doctors who have the time to know their patients (#9, above) and think really hard. The more familiar a doctor is with a person and his or her disease, the more readily she’ll pick up on a change in the patient’s condition, and the more likely she’ll prescribe therapy that meshes with the patient’s values and that works, too. When a physician stays up-to-date, she’s more likely to establish a correct diagnosis and implement appropriate, effective treatment if needed.

So I think better medical education should be added to the list, along with greater compensation for physicians’ time in terms or thinking, reading and communicating with their patients.

minor rev 4/7/10, ES

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