Blog | Friday, August 17, 2012

High value, cost conscious care is the antithesis of too much care


Tara Parker-Pope has written a personal article about her daughter's meandering through the health care non-system, Too Much Care? that most medical tweeters have already referenced. This article has added poignancy because we all see this problem too often:

After years of reporting on health, I considered myself a well-informed patient, but it took my elementary-school daughter to state the obvious: She was the victim of too much medicine. Every new blood test, scan or X-ray raised new questions, which led to more lab work, scans and X-rays. I know the doctors had good intentions, but it's a truism of modern medicine that the more you test and scan and look for problems, the more likely you are to find something wrong. My daughter's case had spiraled out of control.

Once one goes to a sub-specialist for a problem, money becomes no object. Why? Because you have insurance! Insurance means you do not really care how much it costs. Sub-specialists test because that is how they are trained.

We in medicine no longer spend time doing the careful history and physical examination that will minimize these costs. Our insurance system, unfortunately following Medicare's lead, pays more for tests than for a careful examination. A careful history and physical takes time. But we in medicine are not "rewarded" for taking enough time with patients. Our administrators tell us that we have to see more patients per hour. They focus on the volume not the experience.

We give "lip service" to quality, but instead of valuing quality we have equated quality with inane performance measures. We have forgotten Donabedian's classic formulation of medical quality. We have forgotten that he defined quality as multidimensional. Six years ago, in this blog I provided a series of Donabedian quotes that too many people of forgotten:

Which of a multitude of possible dimensions and criteria are selected to define quality will, of course, have profound influence on the approaches and methods one employs in the assessment of medical care.

Many factors other than medical care may influence outcome, and precautions must be taken to hold all significant factors other than medical care constant if valid conclusions are to be drawn.

Judgments of quality are incomplete when only a few dimensions are used and decisions about each dimension are made on the basis of partial evidence.

A major problem, yet unsolved, in the construction of numerical scores, is the manner in which the different components are to be weighted in the process of arriving at the total.

In addition to defects in method, most studies of quality suffer from having adopted too narrow a definition of quality. In general, they concern themselves with the technical management of illness and continuity of care, or handling the patient-physician relationship. Presumably, the reason for this is that the technical requirements of management are more widely recognized and better standardized. Therefore, more complete conceptual and empirical exploration of the definition of quality is needed.


The payment system is broken, and drives us away from high value, cost conscious care. We can only "bend the cost curve" if we remember the root cause. We must remember that the most valuable test in medicine is a careful history and physical. We need generalists--call it primary care if you want--but we need physicians who take responsibility for each patient, both in the outpatient and the inpatient settings. We need to increase generalism and decrease our tendency to overuse subspecialists. We need our subspecialists to remember their generalist roots.

Thanks to Tara Parker-Pope for giving us another reason to consider this issue. We can do better, but only if we can get the "money people" (Medicare and private insurance) to pay the right people the right amount.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.