Role of Doctors
- Almost half believed that inadequate time allotted to patients led doctors to order more tests or refer them to specialists.
- More than three quarters believed that the fear of malpractice suits or of being perceived as not doing enough put undue pressure on them to order more treatment.
- More than half believed that the quality measures and clinical guidelines endorsed by health care experts and insurers as a way of reining in health care costs were in fact having the opposite effect. Ironically, most of these guidelines -- which insurers increasing link to reimbursement -- are based on more testing and treatments.
- Some accuse doctors of prescribing unnecessary care for financial gain. But only 4 percent of the doctors surveyed believed that was a factor. (A brave 4%!)
- incentives that pay doctors and hospitals for individual procedures
- quality assessments that rely on how many patients receive such tests
- physicians' fear of upsetting elderly patients -- or their children -- by suggesting that screening is unnecessary because a patient is too old or too sick to benefit
Screening has become a mantra, trumpeted by advocacy groups. The message to patients is "you're a good person if you get screened," says Dartmouth physician Lisa Schwartz. The message for older patients, regardless of their health, Schwartz continues, should be: "It's not always in your best interest to do more or to keep looking. But we never seem to talk about the downside of testing."
Much of today's health care is provided by specialists. Patients either go to them directly or are referred to them by primary care doctors. The typical patient does not react well if the specialist tells her that she really doesn't require any further treatment or screening.
In some cases, doctors do recommend against testing, but patients demand it. In a recent Washington Post article about seniors' reluctance to forgo traditional screenings, internist Alan Pocinki said he tried to dissuade an 80-year-old man -- a survivor of several heart attacks -- from additional PSA testing. The man's son, a Boston oncologist, agreed. But the elderly patient insisted. The PSA test found an elevated reading, which led to a biopsy, which indicated cancer. Unfortunately, the procedure resulted in the man's contracting a serious infection. Not surprisingly, he wishes he'd never been tested.
BOTTOM LINE ON CONTROLLING COSTS OF EXCESSIVE CARE
For years now, researches have pointed to excessive care as an important factor behind spiraling health care costs. Some studies estimate that up to 30 percent of care delivered in the U.S. is unnecessary and sometimes even harmful. More and more policy makers and insurers have been urging action to address that waste.
But what? As patients, we can all become better informed and take more pro-active roles in test and procedure decisions (part one of this discussion). But, given the problem's dimensions, and the combined tendencies of doctors, patients, and families to choose "more," not "less," the efforts by informed individuals can't make much difference.
It seems to me there's only one solution: Medicare and private insurers begin denying reimbursement for tests and procedures that cannot improve the patient's quality of life, and may even cause harm. But, as we've seen in the firestorms created by proposals to rein in PSA and mammograms, this action would touch the third-rail in our political system -- cutting back current entitlements.
What do you think? What can we do? Is there another solution? Please, share your thoughts!