How to Rein in Medical Costs, RIGHT NOW


    George Lundberg

    I believe that there are still many ethical and professional American physicians and many intelligent American patients who are capable of, in an alliance of patients and physicians, doing “the right things”. Their combined clout is being underestimated in the current healthcare reform debate.

    Efforts to control American medical costs date from at least 1932. With few exceptions, they have failed. Health care reform, 2009 politics-style, is again in trouble over cost control. It would be such a shame if we once again fail to cover the uninsured because of hang-ups over costs.

    Physician decisions drive the majority of expenditures in the US health care system. American health care costs will never be controlled until most physicians are no longer paid fees for specific services. The lure of economic incentives to provide unnecessary or unproven care, or even that known to be ineffective, drives many physicians to make the lucrative choice. Hospitals and especially academic medical centers are also motivated to profit from many expensive procedures. Alternative payment forms used in integrated multispecialty delivery systems such as those at Geisinger, Mayo, and Kaiser Permanente are far more efficient and effective.

    Fee-for-service incentives are a key reason why at least 30% of the $2.5 trillion expended annually for American health care is unnecessary. Eliminating that waste could save $750 billion annually with no harm to patient outcomes.

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    Currently several House and Senate bills include various proposals to lower costs. But they are tepid at best, in danger of being bought out by special interests at worst.

    So, what can we in the USA do RIGHT NOW to begin to cut health care costs?

    An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big ticket items, saving vast sums while improving quality of care.

    1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.
    2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.
    3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.
    4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.
    5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.
    6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.
    7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.

    Why might many physicians, their patients and their institutions suddenly now change these established behaviors? Patriotism, recognition of new science, stewardship, and the economic survival of the America we love. No legislation is necessary to effect these huge savings. Physicians, patients, and their institutions need only take a good hard look in the mirror and then follow the medical science that most benefits patients and the public health at lowest cost. Academic medical centers should take the lead, rather than continuing to teach new doctors to “take the money and run”.

    Physicians can re-affirm their professionalism and patients their rights, with sound ethical behavior without undue concern for meeting revenue needs. The interests of the patients and the public must again supersede the self interest of the learned professional.

    George D. Lundberg MD, is former Editor in Chief of Medscape, eMedicine, and the Journal of the American Medical Association. He’s now President and Chair of the Board of The Lundberg Institute

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    114 Comments on "How to Rein in Medical Costs, RIGHT NOW"

    Mar 8, 2015

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    Nov 30, 2013

    Pretty! This has been a really wonderful post.
    Thank you for supplying this information.

    Aug 3, 2011

    Wonderful article. Glad it’s still available to read. I imagine you must’ve shaken your colleagues enough to make them remove the article from Medscape. Heaven forbid they should profit less from human suffering.

    Apr 2, 2012

    Glad you liked it. I just revisited the article and note that it has remained pretty much on point since publication, as the science evolves and more people begin to realize value.
    You are correct that it was re-published with permission and attribution on Medscape in 2009, received huge readership, and was then removed from the site. I dont know why.

    Jun 29, 2010

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    Feb 8, 2010

    The first two points are idiotic: eliminating CABG and PTCA and replacing it with it “intensive medical therapy” will cost at least twice as much these procedures would alone. It’s a commonly known fact that long hospital admissions are extremely costly, and simply throwing all these patients in the hospital to treat these conditions (which could take weeks), would be an immense cost detriment of unfathomable proportions. The inclusion of these two points makes the rest of the article largely irrelevant.

    Dec 26, 2009

    Influence can be defined as the power exerted over the minds and behavior of others. A power that can affect, persuade and cause changes to someone or something. In order to influence people, you first need to discover what is already influencing them. What makes them tick? What do they care about? We need some leverage to work with when we’re trying to change how people think and behave.

    Oct 21, 2009

    Get a life! Health care is a service, just like legal, accounting and plumbing services. The problems that occur in health care would be duplicated in those professions if the stupid, centrally planned and government controlled medical and health insurance systems were inflicted on them to the extent they are in medicine.
    It makes sense to use the most efficient services, but the misdirected incentives are in place by legislation and subsidies to providers and to patients. With voluntary trade in medical care, the most efficient methods would drive out the least efficient, as they do in every market that is not under the thumb of the state.
    The problem of health care for the poor would be minimal if physician’s customers (patients) acually paid their own bills. The hyperinflation and distortion comes about because everyone wants mercedes coverage witha Yugo premium and they have no personal incentive to minimize costs. Government uses the medical system as another method of redistribution, a policy that grossly distorts the entire market.
    The solution is to get govemrnment out of health care completely. In a truly free market, the massive problems would evaporate. A relatively small number of people would be truly in need of charitable
    medical care, and that need would be filled by charitable people, of which there are many in this great society.

    Milan Prsa MD
    Oct 21, 2009

    WOW! What a load of nonsense! When will we recognize the glaring evidence that economically illiterate bureaucrats just can’t run anything? Governments don’t create wealth in society, they destroy it. This is due to the simple fact that they don’t produce anything and therefore spend other people’s money. It is impossible to do good with other people’s money!!! Anyway, if you’re interested in an intelligent refutation of Dr. Lundberg’s article please read this educational piece:

    Oct 21, 2009

    Unfortunately, Dr. Lundberg (a pathologist, academic, professor, editor, activist), has little real-world experience. His long-term imprisonment in the Ivory Tower has let him where so many others go – Statist control of all of us, by “experts” like him.
    It is a fool who believes that others know, and care, what is best for him.
    Do not be fooled.

    Oct 21, 2009

    Utter tripe. Too much government intervention is the problem. Most of what you cite as unneccesary is in “mandates”, that is, in order to sell insurance in a given geogrphical area, the insurer is forced to pay for tests which may or may not benefit the patient. Get the government out of the business, (because it is, always has been and always will be a business), including licensing, “approving”, and deciding how much a given procedure is worth and let people buy the coverage they need, based on their own assesments of risk etc. This of course requires taking the improperly usurped power from the government and returning it to the people, hardly something you feel is important. End the tax favoured treatment of employer paid premiums and things will chage drstically and quickly for the better. Utilization rates are highest where there is the most government money.

    Dan Smith
    Oct 17, 2009

    Its time to dust off an old tried and true solution to solve a problem like healthcare that the free market cannot solve. In the past when competition was not sufficient to control prices on big ticket items like the price of electricity, price of land-line phone service, and the price of natural gas service, our state governments instituted public service commissions (PSCs) to arbitrate fair pricing. We need a PSC for healthcare to set medical charge code prices billable to the healthcare insurers. All state insurers would pay the exact same amount for identical medical service claims.
    This would stop over-charging and cost shifting. The PSC would investigate patient complaints of wrong doing and have the power to stop corruption. The MPSC would eliminate provider networks and open the door for full-blown wide-open competition among the insurance companies. Without networks and all insurance paying the same, any insurance plan could quickly enter the state, get policies certified by the state, advertise and sign-up new patients state-wide. All doctors/hospitals would be required to accept any state approved insurance.
    The state MPSC could become the healthcare champion needed to stop some of the questionable deeds mentioned above. All approved Medical Charge Codes would be listed on the official MPSC website in numerical order for all to see. You could ask your doctor/hospital for a copy of the bill sent to your insurance and actually check it for errors. If you see a mistake, the insurance company may actually pay you a reward for any money they recover.
    Since the Medical Charge Codes would be standardized by the MPSC, the insurance companies could feed this information (without patient IDs) into a common database for analysis. Effective treatments could be discerned from these data.
    For a particular set of Medical Charge Codes certain diagnostic codes would be acceptable. Extra diagnostic codes deemed as used just to confirm the original diagnosis, could be billed on a pure cost basis only – no mark-up. This would take the extra money out of excessive tests.
    The MPSC would take many of the kinks out of the current system and give us a system uniquely American.

    Oct 14, 2009

    Interesting post. What about the costs associated with long-term care? Another post on this blog suggests these costs total $450b or more annually – consideration of efficiency of service delivery, and careful monitoring of its efficacy cannot be ignored. – Home-Based Stroke Rehabilitation

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    Oct 1, 2009

    as a gm union worker just retired, everyone knows what happened to the auto industry, the high cost was pushed down to the bottom of the food chain. most of these posts are doing the same thing. deja vu dbc

    Jessica - PAC
    Sep 22, 2009

    As a healthcare provider I see way too many patients complaining of a sore throat or a cough they’ve had for less than a day. The number of patients coming in on a daily basis with normal aches and pains is astounding to me. Both the urgent care and I get paid for seeing these patients by insurance companies, so I suppose I shouldn’t complain…But these frivolous visits are a big part of what is driving up the cost of healthcare.

    Sep 14, 2009

    Kaiser is in deep finacial trouble, not a good example.
    Cooperatives DO NOT work, failed in Florida over ten years ago. Competition DOES WORK- Public Option IS a competition strategy.