A Difficult Problem

I've been re-reading Atul Gawande's article about McAllen, TX and healthcare spending. To get perspective on why comparative effectiveness research might not be a bad thing, please note this section:

One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review. Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person. “Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said. Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said. “It’s malpractice,” a family physician who had practiced here for thirty-three years said. “McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere. That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down? “Practically to zero,” the cardiologist admitted. “Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures. The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ” Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said. The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder. Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars. I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago? Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill. And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization. “Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

Even without the looming spectre of a lawsuit, physicians in the modern era order more tests than they need. This is a deep seated side-effect of the incredible complexity of medicine today. This study essentially debunks the myth that physicians practice "defensive" medicine because of the current legal climate. I believe that any physician who is honest will admit that they have ordered unnecessary tests for any number of reasons. I can list several reasons I've ordered unnecessary tests before.

• I misunderstood the problem or the presentation.
• The patient's symptoms seemed out of proportion to the diagnosis.
• The patient's family indicated they expected more testing (verbally or silently).
• I didn't have the time or resolve to argue with a patient who wanted the testing.
• I wanted a shortcut
• I want to relieve my own anxiety

People are appalled by "rationing" of medical care, but you can almost count on your modern physician not to tell you when something is unnecessary either because they haven't read the data and don't understand that it is unnecessary, or they want to be perceived as offering you something, even though that something is just as likely a waste of your time and money as it is an important diagnostic. We need to have an honest debate about what healthcare spending we are going to eliminate, and we will have to eliminate a large amount of our spending. Simply adding to the ranks of the insured, while an admirable goal, (and, I would argue, a reflection of our worth as a society) will not avoid the problem of runaway spending in our healthcare system. As physicians we have to honestly appraise ourselves and admit publicly what we already know privately, we spend our money on the wrong things because they are also the easy things. Care that is proven to be effective, and cost-effective, will not (and should not) be "rationed." We don't need to ration effective care, but we do need to cut the fat, and we need a central authority or clearinghouse to help physicians understand what is effective and cost-effective. Comparative effectiveness research is designed to do just that.