Blog | Thursday, September 27, 2012

How do we achieve high value cost conscious care?

The New York Times has an important and provocative piece, "Overtreatment Is Taking a Harmful Toll."

The title is a bit misleading. The article focuses more on over-testing. We test too much and we treat too much.

The article, while mostly accurate, does not really explain the reasons for the problem Unless we can accept and understand the underlying reasons for these problems, we cannot successful correct these problems.

Let me suggests the major reasons for over treatment and over testing and then address them over the next couple of weeks. Prior to writing about each one, I do want to see if readers can suggest any more or disagree with the list.

Our payment system that pays for each thing (i.e., diagnostic tests, visits) encouraging us to do more things. We get paid the same when we spend less time with the patient and order more tests.

Advances in technology, by which we have better imaging and more laboratory tests. Sometimes the tests are too good, and suggest that we do more tests. Perhaps we should do more careful history and physical exams and do less testing.

Guidelines based on single diseases. We use too many medications to achieve targets that may help a disease but hurt other diseases. Too often we have guidelines that do not give us enough "leeway" to individualize therapy.

Patient demand. Patients think they need an MRI of the head, because a friend said so. That friend knows someone whose 2nd cousin had a rare brain tumor found because of an MRI, thus you must get an MRI.

Malpractice fears. Studies never document this, but all physician know that it is true. This is especially true in emergency departments. Every time I write this my comments fill up with emergency physicians justifying all the studies they do. But ask any hospitalist about excess CTs in the ED. The first abdominal CT for cryptic severe pain makes sense. Perhaps the second, but certainly not the 5th, 6th and 7th.

Marketing from big pharma leads to more expensive drugs and increased patient demand for those drugs. This occurs especially from direct to consumer advertising.

Lack of information from other physicians. Our obsession with privacy and HIPAA decreases the sharing of important medical information across sites. Every time a patient sees another physician the order the same tests because it's easier than trying to get the old results.

I am certain that I have not been totally inclusive in my list. This is really a multi-faceted problem. Please add your thoughts.

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.