High U.S. Medical Costs: “It is the fault of patients, wanting too much and shopping too carelessly”
Why are medical costs so high in the United States?
“It is the fault of patients, wanting too much and shopping too carelessly”
“It is the fault of physicians for giving into the wishes of those patients to keep the patient happy, protect against the patient's malpractice claims or provide additional income for the doctors”
“It is the fault of the insurance companies for giving into the wishes of those patients and the doctors’ orders”
..and who got the patients to want too much and shopping carelessly?
Why.. it’s the media and the TV doctor shows, it’s the pharmaceutical companies, it’s the Internet medical sites, it’s the patient's neighbor who had this and this done for this and this condition. And it is the doctors who give in to their patient's uneducated demands for this and that and add their own self-interest to the mix.
How can we begin to cut the costs of medical care in the United States?
Educate the patient to want less and shop more carefully.
Enough said. Or do you have an argument with this? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:27:00 PM
10 comments
10 Comments:
Dr. Bernstein,
Where did this come from?
Yes it is likely part of the problem, but I don't think it's the cause - or even the biggest contributor. I'd tend to point my finger at things like the widespread practice of excessive "defensive medicine", unnecessary but expensive procedures such as the unnecessary 100,000+ cardiac caths performed on stable angina patients every year, etc. as having a much greater effect. It's about billable dollars - follow the money......
Yes patients are possibly partially at fault for requesting some of these tests or procedures - they watch way too many unrealistic medical shows on TV. It's the physician's responsibility to explain reality to them.
Case in point, if you have a patient present with LRQ pain, positive McBurney's/Aaron's sign upon examination and correlating WBC, why do an abdominal CT? If the patient is female you can do an ultrasound to eliminate the possibility of an ovarian cyst - no need to expose the patient to the radiation from the far more expensive and time consuming CT.
TT
TT, you asked "Where did this come from?" Well, I'll tell you. Last evening on many of the PBS stations was the Frontline presentation of "Sick Around America". The costs of medical care to patients was all oriented to the medical care payment system in America involving the role of government and the private insurance companies. In the hour-long presentation, their was only one wisp of a mention that the costs of medical care can be affected by the patient own requests and demands. Yes, our system is flawed and in these days of high technology and very high costs of some unique drugs for common diseases, there should be changes in how the insurance system works. Yet, in this age of diminished professional paternalism and accentuated patient autonomy, the requests and decisions of patients themselves should be seriously considered as part of the system and what should be fixed. Anyway, that's what I thought might be a good topic to start a productive discussion. ..Maurice.
Dr. Bernstein,
Thanks for the explanation. I agree that the cost of health care in this country has spiraled totally out of control, and something needs to be done.
The way I see it though, any truly effective process to make this happen is going to have to address the issue on multiple fronts, including taking on some "sacred cows" head on. Here's my short list - please feel free to add to it....
1. Since it is the topic of this thread, let's start with patients' requests and demands for specific medications, treatments or procedures. I agree that this is part of the problem, but don't think it's a major piece of the puzzle - still it deserved more than a wisp of mention....
2. Make the standard of card evidence based medicine wherever possible. In my opinion this is a big one. Far to many things are done in the process of health care delivery because "that's the way we've always done it" or "someone thought this was a good idea once upon a time". I'm an engineer, and when I evaluate a process or system I ask myself three questions: What does it do? - How does it work? - How can I make it more efficient and more reliable? Health care needs to do the same thing. If it isn't blatantly obvious why you're doing something, then you shouldn't be doing it.
3. Tort reform - this is another biggie. Malpractice insurance costs not only contribute to the increase in health care costs, but drive practitioners away from high risk disciplines like OB. This is also the driving force behind the practice of "defensive medicine", which results in hundreds of millions of dollars in unnecessary tests every year. Serious reform is desperately needed, and that might mean taking it as far as a no fault system.
It's a very complex issue and I don't pretend to have the answers. I'd be interested in your feedback and anything you might want to add to the list....
TT
TT, I agree with your categorization of the rising costs of medical care in the U.S. The role of the patient (and the family) in raising the costs, especially in the end-of-life phase of medical illness is particularly noteworthy to me since as chair of a hospital ethics committee, I see that contribution of the wishes and requests and demands of family
particularly as the patient enters the end-stage multi-system deterioration for continued energetic life-supportive treatment. And that is beyond the comfort care that all patients deserve and must get. It is this treatment for a cure when no cure is possible and often in a critical care environment which adds to the costs of medical care which someone ends up paying. The reasons for these requests may vary and include religion, hope for miracles, inability to accept the inevitable and even very occasionally for the family's secondary financial gain. And the problem is that a number of physicians, though acknowledging to each other that further energetic treatment is futile, nevertheless follow the family's wishes out of various professional concerns. Another reason for patients and family requesting tests and treatments which would not contribute to cure is because of receiving "mixed messages" from the various consultants on the case as compared with the message from the attending physician. Each consultant, looking at the patient through their own specialty, may provide the patient and family with some chance for hope if this or that is done and yet if one looks at the entire clinical picture, there is no reasonable hope of recovery.
You may find that this link to Science News review ("Study: Doctor-patient conversations at end of life associated with lower medical expenses") of a recent study is appropriate to this thread discussion. ..Maurice.
Dr. B, I suggest you get out and read some of the blogs written by patients with chronic illness (this guy is a good start, and is talking about trying to find a doc today). These are people who want to shop around and make choices based on their cost (and are often stable enough to do so--another problem with any discussion of "choice" in medical practice, often patients are too sick to exercise it--this is, after all, the nature of being a patient).
Yes, uninformed patient request drives some costs, and I think this is something that the US will have to address as part of the coming health care reforms--I also think that doctors have a role to play in this: rather than just giving in because it is the easiest thing to do, docs need to explain why that CT isn't appropriate.
Finally, I think the billing system needs to be looked at--many doctors get paid per procedure, and thus are more likely to do more procedures. I don't think malpractice insurance can be the only reason why the us c-section rate is so high, for example--having insurance increases a woman's chance of c-section (see as ONE example this reference).
In short, I think that patients do have a role to play, but health insurers with their bulk pricing deals, and doctors with their education, and the billing system with its procedure bias have a hang of a lot more to answer for.
NB: I am outside the US, and as such have no skin in this particular game. I just think your system sucks, fails massive numbers of people, and everything I see in the medblogosphere posted by a doc points anywhere but at doctors, and usually at patients. We can't write our own prescriptions, nor do our own procedures.
--PG
Jack O'Sullivan wrote the following today. ..Maurice.
I think that most people think that the system is terrible and reform needs to happen, but who and how are we even going to make a dent in fixing the problem? I don't know that there is a solution. Maybe I am too pessimistic, but that is how I honestly feel.
Jack O'Sullivan
MY COMMENT IS BASED ON MEDICARE FRAUD. WHEREAS, DOCTORS USE COERCION, TO FORCE PATIENTS TO COME TO A DOCTORS OFFICE FOR A FACE TO FACE VISIT, WHEN THAT PATIENT WAS NOT SICK, BUT ONLY NEEDED A PERSCRIPTION REORDERED. WHEN A PATIENT HAS ALREADY HAD A GOOD PERSCRIPTION AND THEY JUST NEED A REFILL, OR IF THE DATE HAS EXPIRED SO THEIR INSURANCE COMPANY REQUIRES A NEW SCRIPT. THESE PERSCRIPTIONS SHOULD BE FILLED WITHOUT THE NEED FOR A MEDICAL OFFICE VISIT; COST $160.00 PLUS TRANSPORTATION BOTH WAYS; IF A TAXI IS USED THAT COST CAN BE $50.00 CASH IN ADDITION TO THE $160.00 CHARGED TO MEDICARE FOR THE OFFICE VISIT; JUST TO GET YOUR PERSCRIPTIONS FILLED. THE THREAT! IF YOU DON'T COME IN, DR. WILL REPORT PATIENT TO ADULT PROTECTION SERVICES. THIS IS COERCION, MEDICAL FRAUD, MEDICARE FRAUD AND MEDICAL WAIST.
DONNA
Dr. Bernstein, thank you for this blog. It's refreshing to hear such clear thinking and compassion about a topic that often descends into pointless rhetoric. I agree with you and the above posters that patient choices,especially regarding end of life care, contribute to our astronomical healthcare costs. However, my personal experience has been that th medical professionals themselves are often the ones suggestting expensive, medically futile, end of life care options. I worked in a nursing home/rehab facility in grad school. One physician in particular often pressured end stage Alzheimer’s patients to accept JEG and PEG tubes, even though it was against their wishes and those of the family. Daily speech, occupational, and physical therapy was performed on every patient in the facility, regardless of its utility to the indivdual patient. Dementia patients spent hours and hours in speech therapy doing useless worksheets for which Medicaid was billed daily. When patients opted for hospice or home care,administrators coerced them into staying at the facility for weeks to months longer.
I have also seen this sort of financial coersion take place in other settings. Case in point,a cardiologist insisted on radiation cath for my father, when all he needed/requested was a cardiac stress test and a cholesterol check. Then there was my own experience with Dr. X, a gastroenterologist. (WARNING: RANT BEGINNING) Within five minutes of meeting me, Dr. X suggested a colonoscopy. Keep in mind that I was 26 with no 'red flags' for colon cancer. I told Dr. X, very respectfully, that did not want the procedure,in part because it was too expensive. Dr. X laughed in my face and haurranged me with tales of $100,000 heart surgery. He pressured me so much that I agreed even though the insurance copay alone almost broke my budget. During the procedure itself, Dr. X took five biopsies of my colon which I did not request or consent to. He also used an a "better" aka pricier anesthetic without my consent. The propofol required a CNA present and increased the bill by thousands of dollars. On a differnt note, side effects from propofol combined with a horrible experience at the outpatient center sent me spiraling into a depression. Now mentally ill and broke, I had to drop out of graduate school.(END OF RANT)
Thank you for allowing me to vent some of my pent up frustrations. Dear readers,thank you for listening to my boring, self involved story. I admire this blog. Perhaps there should be another category titled
" Physician coersion" or " Coersion for financial gain" ?
correction: coercion and harangued. Forgive me, I was typing very fast last night. :)
correction: coercion and harangued. Forgive me, I was typing very fast last night. :)
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