• I applaud the spirit, but remain skeptical

    I just got back from a trip to Disney World (worth a post on its own), and found my mailbox full of clutter. Most of it had to do with the Supreme Court still, which I still think at this point is mostly mental masturbation. The decision has already been made. We can speculate all we want for the next two months, but I’ve got better things to do than play prognosticator. We can focus on all that in June.

    I was, however, intrigued by news yesterday that Choosing Wisely had released their recommendations:

    The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.

    The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

    The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

    Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

    Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

    Look, I’m all for this. I think it’s great. But it’s also important to have a little perspective. None of these recommendations were news to those of us who practice medicine and follow the literature. Seriously, try and find a physician who doesn’t know that overuse of antibiotics for sinusitis is a problem.

    The real issue, as I’ve discussed before, isn’t that doctors don’t have access to evidence. You can say that mammograms should be used less often, but when enough physicians call that “crazy” and “unethical” and label the USPSTF “idiots”, then it’s all sort of moot.

    Here’s another post worth reading. Do you think that if Choosing Wisely said tomorrow we should not use arthroscopic surgery for knee pain all of that would go away? Really? It hasn’t worked yet.

    When I really think about it, I’m forced to admit my skepticism comes from a place of cynicism. I wish that wasn’t the case, but it is. Some doctors fear lawsuits; this won’t change that. Some doctors see a subset of patients that aren’t representative of the general population, and are conditioned to believe that more tests are necessary than really are. This won’t change. Some doctors are influenced by financial incentives that subtly or overtly induce them to do more. This won’t change that either.

    Most of these efforts assume that we can change the behavior of physicians by willing them to do good. I wish that were true. If we really want to change behavior, we have to arm recommendations like these with teeth. Stop paying for stuff we know doesn’t work. Or, make people pay for it out of pocket. If we know something doesn’t work, there should be few people willing to defend using both reimbursement-limiting and consumer-directed means to reduce its use.

    • Quoting Aaron: “If we really want to change behavior, we have to arm recommendations like these with teeth. Stop paying for stuff we know doesn’t work.”

      I weep with joy to see this position advocated but weep with dispair that it will ever be implemented.

    • And changing the malpractice laws won’t help to change this?


      A lot of this is fear driven.

      But I agree, make the patient more financially responsible, directly with larger copays, and a lot will change.

      I would be interesting to see if any study would show that higher personal copays would lead to even more malpractice suits.

    • It saddens me to see Aaron (or any knowledgeable observer) express skepticism, much less cynicism, about the prospects for reducing the use of ineffective or unwise tests and treatments by advocacy alone. It’s hard to disagree that behavior won’t change unless MDs don’t get paid for doing stuff that doesn’t work…or may actually harm.

      For years, I had pretty much the same discussion with a local MD who actively promotes advance care planning and palliative care for dying patients but whose approach was all carrot/encouragement and no stick/teeth. Why do most drivers use seat belts today? Because they were exhorted to, or because they don’t want to get a ticket for failing to do it?

      Let’s be honest, the medical/industrial/advocacy complex will defend testing and treatment (and payment) no matter what the evidence says.

      • Pray tell, what “stick” would a doctor use to “encourage” different decisions by the patient? The doctor has absolutely no financial stick to use with the patient. But the insurance company does.

        • Shared decision making (SDM). Many patients are uninformed. Studies show that informed patients actually want a lot fewer services than are typically provided. If we paid for SDM at the right rate, providers, on average, would be no worse off financially for the lower utilization. Patients would be more satisfied.

          • I revisited your (Austin’s) post on Patient Decision Aids (http://theincidentaleconomist.com/wordpress/patient-decision-aids/ ) and followed some of the links – only to find that the IPDAS Checklist (http://ipdas.ohri.ca/IPDAS_checklist.pdf ) does not even mention COST as information that should be considered in decision making. While this may be more relevant to choices among treatment options (than about whether to screen), as long as nearly all of the “skin in the game” is that of the insurance company (and I think the doctors don’t even know a lot of the actual costs), even those of us who would like to do our part to reign in costs are severely handicapped.

            • Obviously patient and provider cost sharing can play a useful role, if structured appropriately. However, my point was that if through SDM fewer services are delivered, that itself will lower spending. And studies have shown that SDM can reduce utilization. I refer you to Jack Wennberg’s book _Tracking Medicine_.

            • I give general cost/benefit/risk information to patients before I order tests, but the final decision is the patient’s. And when they hear me mention costs, their first response always depends on the copay for the test or procedure. If they pay little, then they want the test.

        • C’mon, Ron, we’re in an asymmetrical information situation here; patients follow pretty much whatever advice MDs give them, and they’ve already got plenty of skin in the game — most of the income gains they would have enjoyed in recent years have gone instead to pay for higher health insurance premiums.

          As the original post made clear, what’s needed is a stick for MDs — no payment when they order tests or treatments known to be ineffective or harmful more often than beneficial.

          Individuals and families will never be able to afford to pay 100% of their health care costs directly, because no one can possibly save enough for the day an auto accident renders them quadriplegic. Save the trollery for a site where readers are less well informed.

          • C’mon, Bill N Roc.
            You’re putting a lot of things out there I never said.
            My point is that most patients don’t consider the insurance premiums as direct costs to themselves. They are paying for a service, many times thinking that the premium should pay 100% of their costs. So they don’t really have to place the money on the table at the time of the procedure, except for the copays, which they do see as direct costs. Why not instead force all employers to increase pay to thier employees for the amount that the employer has been paying for health insurance and have the employee buy the inurance. Then we’d really see some changes.

            The patient is sick and the doctor has to carry all the risk? Huh? Is it the doctor’s fault the patient is ill? This sounds like the old Chinese emperor’s doctors–the doc did well as long as the emperor was well, but if the emperor ever got sick, well, look out.

            I never said the patient has to pay 100%, did I? But a $30 copay isn’t enough for most people to even think about. A $300 copay for an MRI might give some pause, however.

            • “The patient is sick and the doctor has to carry all the risk?”

              That statement expresses a narrow perspective. First, of course the doctor would not carry all the risk. The patient who gets sick loses time, comfort, likely quality of life and possibly even life itself.

              If you are referring to financial risk only, I agree that removing nearly all risk from the individual while also not imposing any financial carrots/sticks for health (such as higher premiums for smoking or being obese) is a mistake. However, that has nothing to do with whether capitation, or a global budget-constrained health system that pays providers on salary and indirectly puts providers at risk for sicker patients, are a good idea. There is a deep misunderstanding here.

              Putting providers at more risk through a comprehensive system is the only way we will control costs while having an adequate amount of equity in access to care. Individual providers need to be put at risk for the controllable aspects of their outcomes and efficiency of care delivered, and the overall system should be constrained by budgets. Like European systems and the VA.

    • I am an older doctor currently winding down my professional career. I think that some of the over-use issues reflect the harried nature of the typical provider’s workload. When you have a fifteen minute slot per patient to see them, complete their EHR, answer phone calls, and listen to their aunt’s theory on why they are tired all the time, you go for the quick fix solution. This means giving antibiotics for sinusitis, MRs for back pain, etc. Of course when the quick fix is congruent with your financial self-interest, then it is a no-brainer literally.
      I think a more pyramidal health-care system would help. I believe that visits should initially be with mid-level providers who would have definite guidelines and protocols. In my expericience with nurse practioners, they do an excellent job of providing routine care and are very appropiate about referral up the chain. Recently, one of my patients with advanced cancer went to an ER with back pain and leg weakness, was seen by an MD, had no imaging, and was paraplegiac from cord compression 24 hours later. I believe that a mid level following a protocol would have been guided to send this case (cancer, back pain, leg weakness) to a high level provider who was not in a rush to clear the schedule.

      • Good points. Sounds resonable. You and I both know there are a lot of issues behind this that the patient just doesn’t realize.

    • Very good comments, it is particularly good to hear the argument from the point of view of the physician. But I would take issue with one statement in the Post.

      “Stop paying for stuff we know doesn’t work. Or, make people pay for it out of pocket.”

      The ‘make people pay for it out of pocket’ assumes that patients are capable of making the decision on these procedures. They are not, no matter how intelligent or educated they are. Patients can only rely on the recommendation of the physician, I mean, what patient is going to say to the doctor “yes I know you want me to have that test or procedure but since I have to pay for it out of pocket I have decided the benefits are not worth the cost”

      Really, this is a problem that can only be solved by the medical profession, not the free market. This of course is the great fallacy in plans like those proposed by Rep. Paul Ryan and others who think private health insurance and market forces will make health care better, more affordable and lower costs.

      • I really don’t understand your reasoning here. The comment to “stop paying for stuff that doesn’t work” seems to be a very brief description that assumes the medical community has done the research and the evidence does not support the use of a particular treatment, which the insurance company picks up on and declines to pay for. So, the patient needs to pay or forget it. That’s reasonable. I have many patients who want their “vitamin B-12 shot”, thinking it boosts their “energy” when numerous studies show it’s placebo effect. But insurances and Medicare won’t pay for it. Some still want it and pay cash, others agree to just take the B-12 orally OTC. Others forget the whole thing. And what’s wrong with that? They have their beliefs, and I give the medical evidence, and they make up thier minds. And I have many other patients who use finances as one of the criteria before deciding whether or not to have treatment or procedures. There is nothing ethicly wrong with that. We do it with everything else in life.

        And I really don’t see your point that “the medical profession” is the one to solve the health care dilemma. There’s quality, quantity, and cost and those 3 things are never going to agree with 100% of the people.