It’s the intensity, stupid

Of course it’s many things. Among them, Victor Fuchs highlights the difference in intensity of medical care between the U.S. and other OECD countries.

The OECD countries provide more physicians and more acute care hospital beds, whereas the United States provides much more high-tech services, such as magnetic resonance imaging (MRI) scans and mammograms, proportionately more specialists, more amenities (privacy and space in hospitals), and more standby capacity as evident in a higher ratio of MRI scanners available to MRI scans performed. The greater number of physician visits and hospital days in OECD countries does not result in higher spending because of differences in services provided during a visit or a hospital day. In general, the United States has an expensive mix, whereas the OECD countries have an inexpensive one.

Of all the factors that drive inefficiency in U.S. health care, at the moment I’m drawn to this one. Of course the high intensity of U.S. practice is driven by financial incentives affecting both provider and patient. But it is also cultural. Patients should not so quickly presume that the service offered is one they should have or even would want if fully informed. Nancy Kressin quotes Gilbert Welch as suggesting

patients ask, “Why are you suggesting this test?” “What is the accuracy of this test?” and “What will we do if the test is positive?”

These are questions that should be asked even if one’s out of pocket cost is zero. For the cost of an unnecessary* test or procedure is measured in more than dollars. It could do more harm than good.

* “Unnecessary” is not the right word since it suggests a dichotomy that is not always present. Every test or procedure has an associated cost-benefit ratio, even if only imprecisely known or knowable. It’s not that the marginal service may be unnecessary — though it may be — but that its benefits may be low relative to the cost, measured in more than dollars and including all risks of complications. Of course, in some cases the benefits are high relative to cost. But one can’t know the difference if one doesn’t ask.


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