Will Doctors or Patients Bend the Cost Curve?

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don't provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU).  The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is - will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won't likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor's income. Some on the list of Choosing Wisely, however, will.

Take a look at the recommendations by the American Gastroenterological Association specifically around the need for repeat colonoscopy after a normal one.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

Yet, if a doctor does fewer colonoscopies, which is the right thing to do, that also means his income will decrease. In the fee for service reimbursement system, doing fewer procedures means fewer things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece "Do Patients Want More Care or Less"? 

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”... [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.

Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one "just to be safe?" Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn't necessary, how an individual's personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn't talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won't be the result of our professional organizations rolling out an educational component, or the media highlighting the "waste" in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the "father" of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,"

“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”

“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”

In the end, it will be doctors who can bend the cost curve.

Save Money on Medical Costs - Get Your Old Medical Records

There are many tips to saving money on medical costs like asking your doctor only for generic medications, choosing an insurance plan with a high deductible and lower monthly premiums, going to an urgent care or retail clinic rather than the emergency room, and getting prescriptions mailed rather than go to a pharmacy.

How about getting your old medical records and having them reviewed by a primary care doctor?  It might save you from having an unnecessary test or procedure performed.

Research shows that there is tremendous variability in what doctors do.  Shannon Brownlee's excellent book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer , provides great background on this as well as work done by the Dr. Jack Wennberg and colleagues on the Dartmouth Atlas.  Some have argued that because of the fee for service structure, the more doctors do the more they get paid.   This drives health care costs upwards significantly.  Dr. Atul Gawande noted this phenomenon when comparing two cities in Texas, El Paso and McAllen in the June 2009 New Yorker piece.

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

Doctors apparently seemed to order more tests.  Patients, not surprisingly, agreed.  After all, without adequate medical knowledge or experience, how sure would you be if a doctor recommended a test and you declined?

Would doctors do more because they get paid more or would they simply do the right thing and do tests or procedures when only medically necessary?

I recently had a 55 year old healthy woman join my practice.  She wisely had brought in her medical records and was fairly educated on the care she received.  She told me that her previous doctor had recommended a colonoscopy for this year, five years after her initial colonoscopy at age 50.

Odd. 

For most patients with no family history of colon cancer and a normal colonoscopy, recommendations are to repeat in ten years not five.

Did she have any abdominal pain or change in bowel habits?  No.

Did the doctor say anything about colon polyps or growths?  No.

Did she have the colon biopsied?  No.

Was there a family history of colon cancer?  No.

She was pretty sure she was to have a repeat test five years later.

I reviewed her previous doctor's chart which had her colonoscopy report.

Completely normal colonoscopy.  No polyps.  No growths.  No biopsy.

At the end of the report:  Recommend repeat colonoscopy in 5 years.

I've read news reports over the years where research has noted some gastroenterologists were doing colonoscopies more frequently than recommended by their own professional medical societies either for routine screening or follow-up of colon polyps and growths.  I assumed those stories were outliers and rare.  I would never encounter such an obvious case of overtreatment.

But this patient's report and her memory of what her doctor told her could not be chalked up to a typo or a misunderstanding.  Would doctors do more because they get paid more?  How else to explain this?

After showing my patient the guidelines from the American Cancer Society as well as the American College of Gastroenterology, she was thrilled that she didn't need to undergo the procedure for another five years.  No need to do the prep that Dr. Oz did with the gallon of laxative and the loss of a day getting ready and then recovering from the side effects of IV sedation needed for the colonoscopy.

I saved her time and money and unnecessary treatment.

You should always have a primary care doctor review your old medical record, especially if you move or switch insurance plans.  Another doctor's opinion and insight can be very important to counter this natural feeling of uncertainty.  No one wants to make a bad choice.  Patients aren't medical experts and generally don't want to be.  Doctors who choose primary care do so because they want to care for the whole patient despite the fact it is among the lowest paid specialties and least attractive to medical students.  Medical students are gravitating towards specialty care which are more procedural based and therefore have the opportunity to generate more income.

Unfortunately, this means doctors who can help patients make informed decisions and prevent overtreatment will be in limited supply at a time when we need them the most.

Want more helpful tips? Worry about whether you are getting the best medical care? Does your doctor seemed rushed? Not answering your questions? I have a solution for you!

Too Much Radiation From Medical Scans? Antidote is a Superb Primary Care Doctor.

The Associated Press has been running a fantastic series of must reads with the latest article highlighting the consequence of too many imaging studies, like xrays and CT scans, which are the biggest contributor to an individual's total radiation exposure in a lifetime. Americans get more imaging radiation exposure and testing than people from other industrialized countries.

Reasons for doing too many tests include malpractice fear, patient demands for imaging, the difficulty in obtaining imaging results from other doctors or hospitals, as well as advanced technologies, like coronary angioplasty, which have increased radiation but avoid a far more invasive surgery like heart bypass.

Although these are all legitimate concerns, one of the reasons listed was , include:

"Accuracy and ease of use. Scans have become a crutch for doctors afraid of using exams and judgment to make a diagnosis. Some think a picture tells more than it does. Imaging that shows arthritis in a knee or back problems doesn't reveal how to make it better, said Dr. Richard Baron, a primary care doctor in Philadelphia."

Dr. Baron was recently widely cited for his article in the New England Journal of Medicine on the true workload of primary care doctors which gives valid reasons why medical students as well as those in practice are avoiding the specialty or retiring respectively.

It really isn't accuracy and ease of use as Dr. Baron suggests, but rather a matter of survival for doctors on the front-line. The vast majority doctors are paid fee for service. That is the more you do the more you get paid. In the case of primary care doctors, the more patients you see the more you get paid.

It has been argued that if primary care doctors were paid a salary instead of by number of patient visits that more time could be spent on asking the right questions and doing thorough examinations to get to the root of a patients problem. When I train first-year medical students, I tell them exactly the same thing: If there is only one thing you learn from me, then it is how to take an accurate history and a relevant physical exam. Ninety percent of getting the right diagnosis is refining these two skills.

Students often ask how long it takes to be good at this.

A lifetime. Professional athletes, artists, and musicians never stop getting better and as doctors neither should we.

Why is this important?

Because the latest thought in healthcare is to slow costs by pushing more financial responsibility to patients. A report by the consulting firm PricewaterhouseCoopers found that majority employees will face a deductible of $400 or more, which is in addition to the annual premiums. Will patients really be able to ask or even challenge their doctors on the appropriateness of an imaging study? Do you ever tell your auto mechanic to not service your car when the airbag indicator or the brake light come on? (If you have, please let me know because I certainly didn't have the courage to do so).

The other thought is to make prices for procedures more transparent as start-up Castlight tries to do. Shop around for the cheapest imaging study. Although this also is a laudable approach to slow healthcare costs, it is also not addressing the root cause. Doctors are ordering too many tests. Though price transparency will make the unit cost of the test cheaper, Americans will still be overdosed with radiation.

Doctors need to step up and lead the way. They cannot until the reimbursement system changes that values primary care for time spent thoughtfully evaluating patients by talking and examining them. As Dr. Abraham Verghese of Stanford Medical School and an outstanding clinician notes, it is the patient's story that matter not the imaging tests. As he correctly argues in an editorial in the British Medical Journal

...clinicians who are skilled at the bedside examination make better use of diagnostic tests and order fewer unnecessary tests. If, for example, you recognise that the patient’s chest pain is confined to a dermatome and is associated with hyperaesthesia, and if you spot a few early vesicles looking like dew drops on rose petals, you have diagnosed varicella zoster and spared the patient the electrocardiography, measurement of cardiac enzymes, chest radiography, spiral computed tomography, and the use of contrast that might otherwise be inevitable. And so many clinical signs, such as rebound tenderness, lid lag, tremor, clubbing, or hemiparesis cannot be discerned by any imaging test.

To avoid overtreatment and save money, find a superb primary care doctor will to talk to you about the pros and cons of medications, imaging tests, and procedures. Be thankful she did. As the Associated Press series of Overtreated articles illustrate, sometimes it is best not to keep up with the Joneses and walk away from too many tests while still staying healthy.

Can't find a stellar primary care doctor? No worries. The truth on how to avoid the traps of overtreatment are found in my book which is available on Kindle, iPad, and iPhone, as well as hardcover. This easy to read book offers the skills I use to keep my patients healthy while thoughtfully ordering treatments they really need to stay well.

Overtreated: More medical care isn't always better. Doctors must lead change.

The Associated Press recent article "Overtreated: More medical care isn't always better" reiterated a commonly known fact which is not understood by the public. This problem of doing more and yet getting little in return is a common issue which plagues the US healthcare system and was illustrated quite convincingly by Shannon Brownlee's book. Americans get more procedures, interventions, imaging, and tests but aren't any healthier.

In fact they are often worse off. Too many unnecessary back surgeries. Too many antibiotics for viral infections, which aren't at all impacted by these anti-bacterial therapies. Too many heart stents which typically are best used when someone is actually having a heart attack. Research shows that those that are treated with medications do just as well. As all patients with cardiac stents know, they also need to be on the same medications as well.

Eliminating unnecessary treatments is a good thing, particularly when it is based on science.

Already over the past year, cancer screening guidelines have been updated based on reviews of the latest medical evidence. Prostate cancer screening with blood test PSA does not appear to be helpful in determining which men have the life threatening aggressive form requiring treatment and which men have the indolent version which will never impact their health. Some medical experts have suggested that breast cancer screening with mammograms should be moved from age 40 to age 50 based on the review of studies.

You would think the public would be happier that they would be poked and prodded less as scientific evidence shows that it is safe to do so. We should want the healthcare system to be in the mindset of continual learning and not mired in old traditions just because that is the way it was always done.

Yet despite this reality, some people view this as rationing of medical care or the beginning of socialized medicine.

It's not. It's the time of rational medicine. Doctors need to lead the change and get away from the hype and more to the science. That is what patients really want. What is particularly disappointing is that overtreatment is well known and already profiled in various articles two years ago. Change is occurring very slowly. It is unclear why. Despite being bombarded with pharmaceutical advertisements, body scans, and easy access to medical information, patients still trust doctors the most for advice.

If we as doctors fail to lead, then patients will be left to figure it out themselves.

And they are already fearful.