Health Law Does Little to Curb Overuse of Care: nyt #hcr #hcsm

Dr. Robert Colton, an internist in Boca Raton, Fla., has a problem, and he knows it. His patients come in wanting, sometimes demanding, tests and treatments that are unnecessary, just adding to the nation’s huge health care bill. He even has patients, he says, who come in and report that their chief complaint is, “I need an M.R.I.

And what does Dr. Colton do?

“I do the damn test,” he said. “There is no incentive for me, Rob Colton, to reduce overutilization. If the person wants it, what are you going to do, say no?”

And the new health care legislation, he says, is not going to make a bit of difference.

 

Consider this an addendum to my post last week….   If we do not curb over-testing – over-utilization we will NOT be able to cut costs… period!

I never considered the fact that docs want to be incentivized to control this…. I thought it was a logical way to control costs and simply part of our obligation to educate patients about what tests are or are not necessary.  Take a Cat Scan for instance.  If a patient demands a CT… am I simply going to order it… NO.  Do they understand the risks of cancer, radiation exposure, etc…. 

Docs… we can step up and control costs… limiting expenses to provide a better world for our children should be all the incentive you need! 

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About hjluks

A busy Academic Orthopedic Surgeon, Digital Strategist, Chief Medical Officer and father... intently and efficiently navigating the intersection of Social Media and Health Care.
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3 Responses to Health Law Does Little to Curb Overuse of Care: nyt #hcr #hcsm

  1. Howard Luks says:

    This was sent to me by a colleague who wished to remain anonymous…While I agree with your assertion that doctors need to limit unnecessary tests, the premise that doctors can simply auto-limit such studies deserves further inspection.Take for example, the office of a busy internist or family physician. To make an average income requires these clinicians to see in excess of 25 patients a day, and to also do a significant amount of “free” work, on the telephone, reviewing charts, calling patients, relaying test results, coordinating care, etc. This unreimbursed total averages 40% of the primary care physicians actual workload. Their average patient has 8-10 active medical conditions, not to mention 10-12 conditions that require screening. The patient, mistakenly believes that he is there for his or her acute problem..usually more than one, which requires yet more time be dedicated to this individual. Complaints in this setting generally arise along two fronts…my physician did not spend enough time with me, or my physician made me wait. Primary care has roughly 5-7 minutes to see such a patient, 5 minutes to write in the chart and another 3-4 minutes for the nurse or other personnel to get their job done. For their effort they are reimbursed $35-85.Given this current scenario, the primary care physician is forced into the peculiar situation of trying to be “thorough” so as to not over look anything (which might result in legal or professional action or at the very least a great degree of personal guilt that your inaction had caused harm) while at the same time maintaining a sense of connection with the patient (which in this day and age is a bit like a hurried parent giving their chidren everything they want as a way of compensating for the inability to provide true, undivided, attention) and also trying to juggle the financial reality of their business.What ensues is that far too many, many thousands of dollars for studies and tests are inappropriately liberated. Patients, have come to accept technology as an acceptable surrogate for their insecurities and have lost any sense of respect for the patient-physician relationship; because under the current system of hamster wheel medicine, the illusion that any such relationship exists is a sham.This illusion is perpetuated by the false belief that we as a society can technologize ourself into immortality. We fear death, we lack relational understanding of and interaction with the subject matter and so we pray to the false gods of electron spin cycles to show us what our problem is…overjoyed for a period by our good fortune that the current temporary illness, confirmed via magnets or radiation, is not the horrible malady our insecure consciousness imagined.Furthermore, there are some instances where “damn the costs” the situation demands that the patients and physician must know. That more and more patients and physicians ascribe to this belief pattern illustrates that at some level we all think of ourselves as essential beings, worthy of our own self preservation.Moreover, there are times, when expensive tests and procedures yield an illusive diagnosis or offer survival benefit to the recipient. Some tests, though expensive, are just “good” medicine, though they may not fit the strict economic utilitarian litmus tests envisioned by health care rationing authorities.Furthermore, the court does not recognize any responsibility for their part in perpetuating the destruction of the house of medicine, by denying the foundations upon which relationships are made and sustained. Patients are looked at as possible future litigants while clinicians are viewed as purveyors of possibly noxious medicants or inept mechanics who seek procedural flesh only for the goal of self enrichment. Authoritarian licensing agents seek to ally the publics fears by providing forum for complaints, but neglect to provide one for self improvement and the reduction of future mistakes.The words of present day relationships are plausible deniability and defensive documentation and risk management. Aversion to absolute honest dialogue has been replaced with structured and scrubbed communications, vetted through a bewildering array of filters and safeguards meant to “protect” the patient from any sort of privacy breach.Medicine mirrors society in many respects. Fear, anxiety, uncertainty over the future, hype and hyperbole dominate our political and societal landscape. Lasting relationships, even lasting convictions, are discarded for the faddish and fleeting fancy of the day.The return to any sort of sanity and cost containment in medicine, in this authors humble opinion, lies in the reinstatement of this relational mandate that has served medicine, both patients and their caregivers well, since before the time of Maimonides. The enactment of laws and policies will do only so much. Society must be willing to move beyond the current culture of fear and and insecurity and embrace a new vision of hope and acceptability. Only then, will true, meaningful and sustainable change be a reality.

  2. Brian Ahier says:

    I agree that the health reform legislation does very little to control costs…Howard, don’t you think that one fear providers face is that limiting tests could come back to bite them if it ever comes to a lawsuit? An OB/Gyn was telling me that without some liability reform, then not only won’t we control costs, but we may have a hard time keeping practices open due to the high cost in many specialties of malpractice insurance.

  3. Howard Luks says:

    Brian… That certainly is the observation (excuse) many physicians will offer you for their inability 9 (or lack of desire) to limit testing and control costs… but I humbly disagree with them. It is too easy to order tests, or go along with a demanding patient who insists on a battery of tests, or prescribe a brace or an MRI when there is no clear indication. Not everyone with shoulder pain needs an MRI, not everyone with back pain needs an MRI, etc… I can not tell you how many 75 years olds I see in the office for knee pain and the only imaging study they have had to date is an MRI. No one obtained a simple X-ray which would have shown you the arthritis and enabled you to proceed with the appropriate treatment, without compromising their results–all without the need for an MRI. Does everyone with a meniscus tear need surgery, does everyone with a rotator cuff tear need surgery, and does everyone with osteoarthritis needs a total knee replacement. The obvious answer is no. Not all ankle/wrist or knee sprains need a brace. Most overuse injuries that show up in your office on Monday would have resolved spontaneously if the patient had waited 3-5 days. I have no problem seeing them and educating them… and leaving the door open for further study if rest, anti-inflammatories and ice do not work over the course of a week.— or am I going to send all of them for an MRI, CT, etc? Many patients will demand a Cat Scan. Then I review the relevant data on radiation exposure, and cancer risk with them and the typical (well accepted) indications for the study and their desire to have the study will diminish dramatically. If we spent a little time teaching and educating our patients about the natural history of most injuries or disease states, instead of worrying about our OR schedules, or keeping the MRI we purchased busy, we would significantly decrease the demands for further testing…. and the amount of time needed is not significant. And we haven’t even touched on the significant potential downsides of chasing all the *incidentalomas* we discover, test further and treat as a result of over-utilization and over-testing. Of course there are those who will disagree and I welcome their comments. (This is simply my opinion and nothing that I stated is meant as medical advice)

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