Physicians

Will Doctors or Patients Bend the Cost Curve?

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don’t provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU).  The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is – will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won’t likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor’s income. Some on the list of Choosing Wisely, however, will.

Take a look at the recommendations by the American Gastroenterological Association specifically around the need for repeat colonoscopy after a normal one.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

Yet, if a doctor does fewer colonoscopies, which is the right thing to do, that also means his income will decrease. In the fee for service reimbursement system, doing fewer procedures means fewer things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece “Do Patients Want More Care or Less”?

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”… [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.

Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one “just to be safe?” Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn’t necessary, how an individual’s personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn’t talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won’t be the result of our professional organizations rolling out an educational component, or the media highlighting the “waste” in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the “father” of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,”

“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”

“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”

In the end, it will be doctors who can bend the cost curve.

Davis Liu, MD, is a practicing board-certified family physician and author of the book, “Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.” Follow him at his blog, Saving Money and Surviving the Healthcare Crisis or on Twitter, davisliumd.

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Prenatal FitnesslhfBarry CarolDeterminedMDJonathan H Recent comment authors
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Prenatal Fitness
Guest

Being a well educated patient is key….with all the info out there on webmd and being able to research on youtube, patients need to arms themselves so they don’t feel as intimidated when the doctor starts talking about various tests and procedures

lhf
Guest
lhf

It requires a well educated patient to make an Informed decision about choices in medical care. It happens to be an interest of mine, so I read alot and have frequently declined tests and medications. Lately I’ve found doctors are more receptive to that point of view, but 20 years ago I had a huge fight with an obgyn who wanted me to take hormones. She gave me the standard list of horribles that would ensue if I didn’t and then demanded that I sign a waiver stating that she had recommended and I had refused her advice. Of course,… Read more »

Barry Carol
Guest
Barry Carol

I think there is a lot more that employers can do to help make employees better understand the connection between the cost of health insurance the employer is paying on the employees’ behalf and why their wages are growing slowly if at all. Economists know that the cost of employer provided health insurance and other benefits for which the employer pays cash or incurs a liability to provide benefits in the future (pensions) is part of the employee’s total compensation but many employees don’t. A simple annual statement providing this detail would be helpful. Letting employees know that lots of… Read more »

DeterminedMD
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DeterminedMD

Watch for the antiphysician attack dogs on these threads, they are well trained and also are not interested in discussion that refutes their alleged claims. Sort of like the partisan crap out of DC? And by the way, just listen to the bitching by patients in their copays when they demand, not ask mind you, for brand name drugs. Everyone want a free meal, but, when it comes time for settlement of the bill, everyone is ducking for the door. And my money says these antiphysicians just stand by it and shout their souless platitudes and then tie on the… Read more »

Peter1
Guest
Peter1

Dr. Mike says: “That’s your reply? Really?”

Well Mike, tell me about the overwhelming pressure that a doc must do what the patient tells him/her to do? Really, tell me.

Nate Ogden
Guest
Nate Ogden

malpratice lawsuit? Take their business elsewhere? Its really easy to have strong morals when your getting a paycheck from someone every week. When you own a business and have to serve people its not easy watching them take their business elsewhere for gray areas. Is it illegal to give someone an MRI they don’t need, not at all, not even morally questionable, so why if the patient is demanding it would you refuse to give it to them? Getting their rep blown up online or bad mouthed in public Flip the question Peter, what does the doctor have to gain… Read more »

Peter1
Guest
Peter1

Hmmm, grey area eh. Well if it’s so “grey area” then maybe it has some validity worth testing for. If a hypochondriac came to a doc’s office and demanded treatment would it be ethical for the doc to treat a non-existent disease because “the business will just go somewhere else”? Isn’t that what Medicare fraud is all about? Seems you want all the “morals” to be with the patient and let the doc off scott free.

MD as HELL
Guest
MD as HELL

It all depends of the relationship. Peter. If there is no relationship, then you get the test. If there is a trusting relationship, then you do not if it is not needed.

Nothing about the direction of healthcare today is about the patient having a relationship with his doctor. Often we are not even talking about a doctor… a “provider”…what a POS term that is.

Jonathan H
Guest
Jonathan H

You don’t like the term “provider,” so what is a better general term that encompasses doctors, hospitals and all those who can deliver and bill for medical services? Providers aren’t just doctors.

Also, you dislike this term, presumably because it frames doctors in terms of their economic role in the system, but in the same post seem to endorse acting on purely economic motives when you say that docs will do unnecessary care for patients when there isn’t a “relationship.” That looks like the action of an economic agent.

DeterminedMD
Guest
DeterminedMD

per MDaH above comment, on the mark! We really don’t have relationships anymore with our “consumers”, “clients”, or worst, “customers”. Health care really did get dumped with that giant POS when we allowed the business model to take hold.

And per my prior reply below, to humor somewhat the antidoc crowd, my money is on most if not all are just business focused, profit mongering, and partisan protecting people.

Provider, not a great term, but at least not called health care serviceman/woman. At least not yet!

Peter1
Guest
Peter1

“Flip the question Peter, what does the doctor have to gain by saying no? Absolutely nothing.”

Nate, it’s called professional ethics. Doing the right thing rarely gives a monetary return.

Nate Ogden
Guest
Nate Ogden

seldom pays your mortgage, puts your kids through school, or settle your student loans either.

If you rely on the ethics of others your going to frequently be disappointed.

Peter1
Guest
Peter1

Then you’d agree that Medicare fraud is about paying your bills, putting your kids through school and paying student loans.

Exactly what does you priest say about such an outlook? Or does confession just wipe it all out?

Nate Ogden
Guest
Nate Ogden

your being an idiot again. Wouldn’t you need to ask the priest of the people committing those acts moron?

Are you further saying all providers are christians? Why would a muslim provider confess?

Do you try to come up with the most stupid comment you can or are you really this thoughtless?

Nate Ogden
Guest
Nate Ogden

whats wrong in your head Peter that you somehow drag my religion into Medicare fraud? Its a shame that people like you are allowed to vote.

Dr. Mike
Guest
Dr. Mike

HVAC guy says I don’t need a new furnace. I say put one in anyway and in it goes. Mechanic says I don’t need the transmission relaced, just serviced. I say put one in anyway and in it goes. Lawyer says I won’t win. I say I’m suing anyway. Lawyer is happy to collect his fee. Doctor says I don’t need an MRI. I say I want one anyway and off I go to the radiology department. Why is the doctor the only evil one out of the four? Only because big insurance and big government say so. Don’t give… Read more »

Peter1
Guest
Peter1

“Why is the doctor the only evil one out of the four?” Well if your examples had any kind of relevance I would say that no one forces docs to perform unnecessary procedures. People just can’t go to a surgeon and demand an operation, it requires a diagnosis and many times the outcome is unpredictable or at least foggy and open to percentage risks. Health care IS different because no one dies if their HVAC or their transmission is not replaced. As well if mechanical things start to cost too much money you can just replace them – ever tried… Read more »

Dr. Mike
Guest
Dr. Mike

No one forces any one of the individuals in my examples to do anything. And an MRI is in my example neither life-saving nor life-altering in any way. As Nate correctly points out, if the patient was paying for the MRI NO ONE WOULD CARE. But because the Insurance company is paying, suddenly the doc is at fault if he gives in to pressure from the patient to order an unnecessary test. So it is obvious that my allegiance in your utopian world of third party payers is to the third party payer and not to the patient.

Peter1
Guest
Peter1

“suddenly the doc is at fault if he gives in to pressure from the patient to order an unnecessary test.”

What pressure, a gun to his head?

Dr. Mike
Guest
Dr. Mike

That’s your reply? Really?

Nate Ogden
Guest
Nate Ogden

wait till you get BobbyG’s “copy that”

Jonathan H
Guest
Jonathan H

Wait, what, Dr. Mike? I’m still trying to make sense at why you think those cases are analogous. When a third party is paying (whether private payer or government) they have a fiduciary responsibility not to waste other people’s money. Because ultimately other people are paying. It is morally irresponsible, non-functional, socially self-destructive, etc., to give carte Blanche to the providers and individuals requesting care without oversight. This, by the way, applies in any situation where you have public or private insurance. You can’t just get a new house built for no reason and have homeowner’s insurance pay for it.… Read more »

Nate Ogden
Guest
Nate Ogden

patient doesn’t need the doctor to bill insurance they can do it themsevels. This also falls apart as soon as you consider Medicare which by law must pay then later a couple years down the road take into consideration their fiduciary responsibilty. With government paying 50% of cost the lack of any fidicuary responsibilty is a huge problem. Ya mythical 3% admin.

Jonathan H
Guest
Jonathan H

Nate, are you just arguing for the sake of arguing? The degree to which Medicare meets its fiduciary responsibility has nothing to do with my point that it has one, as all payers do. And in any case Medicare and other govt programs do impose all sorts of restrictions on what they will pay for. My point is that the responsibilities exist and should exist for all payers. The details are another discussion. That patients can submit claims is true, but again not really relevant to the point. I can add a clause to the penultimate sentence of my previous… Read more »

Nate Ogden
Guest
Nate Ogden

Not at all, I disagree when you say Medicare has a Fidicuary responsibility to pay claims in a financially prudent manner. We might like to think it does but the law clearly says otherwise. If Medicare did have a fidicuary responsibility Medicare would be saving over $50 billion per year and the per member cost would be $700 lower annually. The very first healthcare reform before we allow government anywhere near the private system should be to fix medicare. Until the government can display some modicame of fidicuary responsibility in the present system all talk of expanding those systems should… Read more »

Jonathan H
Guest
Jonathan H

Nate, again you are missing what my response to Dr. Mike was all about. It was just that payers have a responsibility to watch after what they pay because waste impacts not just their finances but also takes money from other people who pay into the pool. This is a normative point primarily, so your comments about Medicare only reinforce what I’m saying. you agree it should have this responsibility and disagree with Dr. Mike who thinks insurers should pay for whatever he wants to do. As for whether Medicare lives up to its obligations, we can agree it has… Read more »

Nate Ogden
Guest
Nate Ogden

first three cases your spending your money. If you were paying for needless MRI with your personal money no one would care. With wasted healthcare it feels more like the Obama weatherization scam where the HVAC guy was robbing the tax payor for unneeded and overpriced work.

I agree with your point though, not insuring routine expenses would be a great first step.

Denny Brennan
Guest

Peter and Peter – Excellent discussion. I believe that some of your tipping prices are too low, Peter1. I don’t know if $5 bucks is enough to move me from my pharmacy, either, given how difficult my PBM’s analog requirements make my life . People learn to make other non-transaction decisions that save boat loads of money and forestall a regret-filled future, however, including choosing not to need a TURP, an angiogram, coronary angioplasty, insulin, or dialysis because I’ve been informed of weighted probable cost in quality life years some of these exact and what I can do with other… Read more »

Peter1
Guest
Peter1

Denny, we manage the public risks and effects of alcohol and tobacco with consumption taxes, would you agree to a similar tax on sugar and fat?

It’s funny when people start wanting restrictions on health care consumption (usually someone else’s) people start shouting, “DEATH PANELS!” – remember? Putting patients in the role of doctor doesn’t necessarily produce better medical decisions, especially when money is used to punish patients for taking what might be the proper decision. It means those with means get to hog resources while those without get to gamble on higher risks.

Peter@selfpaymri.com
Guest

Patients get my vote..

As deductible levels move way up folks should get a bit more proactive and engaged with their cost of care. Some of the most popular plans now start at $10K deductibles. Offer incentives below these caps for healthy and cost conscious behavior.

We don’t file an insurance claim to change our car’s timing belt or our home’s paint job – both are investments. I hope the masses can move in this direction.

Peter
selfpaymri.com

Denny Brennan
Guest

As long as value (outcome relative to cost) and effectiveness (relevance in addition to efficiency) go up, payers will be happy. Getting the same outcome for fewer dollars is one way money goes back to the person who paid in the first place. Not the insurance companies…they’re intermediaries, but to the person who pays the premium (e.g., taxpayer, employee (as part of their total comp), individual buyer (me as mandated by Massachusetts, pensioner). There are examples of the public stepping up, but they’re not found in the segments you cited, Davis. They’re in the public and social utility areas (education,… Read more »

Davis Liu, MD
Guest

Can you elaborate on the public stepping up in the areas you describe and how they apply to health care?

Denny Brennan
Guest

I had to go back and read your original post to find the forest for the trees. You state that “If we expect doctors or patients to bend the health care cost curve …with more education, better communications, …we will fail.” This is a sophistry. No one expects education and communications alone to make the difference, but that doesn’t argue for an uninformed and uneducated patient and no discussion with the doctor. You state that people now call you to get tests without seeing you. Self-referral is a problem but it will only worsen if the doctor refuses to discuss… Read more »

Davis Liu, MD
Guest

Agree with everything you say, however, would note the following. My thoughts about whether more communications will be helpful is taken from the doctor who penned the NY Times piece as noted below. The movement toward a more restrained view of medical care raises an obvious question: Could improved communication, informed patients and increasing health literacy help to slim down a bloated system — and improve American health? As a physician planning to attend the Boston conference, I am hopeful. I am engaging patients who simply want to jump to a MRI before an office visit. That does not mean… Read more »

Jonathan H
Guest
Jonathan H

Davis, I think there is a short answer to your question: Yes, if doctors are paid more for better engagement. It doesn’t have to be direct payment on a FFS basis. Indirect payment through salary with job reviews that look at appropriate utilization, patient reviews, etc., can work just fne.

Denny Brennan
Guest

All good points and well taken. My knowledge of the existing guidelines is what I acquired playing a doctor on TV. They’re andecdotal/heresay, but I think we’d agree that, being so, I and my patient cohort would like our doctor, or his/her practice to spend a little time getting us up to speed. You, the doctor, don’t have to do it, but I, the patient, need help with getting smarter so that my doctor and I make better uses of our time. I don’t advocate my getting labs beforehand but why can’t I get the complete Annual Wellness Visit, a… Read more »

Davis Liu, MD
Guest

Thank you for your thoughtful responses. I very much look forward to learning more about your “pre-primary patient engagement and health assessment technology and services turnkey process partner for medium to larger primary care and multi-specialty groups.”

I believe in the end we want the same thing and are approaching the issue from two different and yet relevant perspectives.

Denny Brennan
Guest

Bit of a mouthful wasn’t it? Sometimes I hate computers and keyboards…

Peter1
Guest
Peter1

“bend the effectiveness and value curves in the right direction”

Depends on who’s paying, doesn’t it?

Denny Brennan
Guest

They may not bend the cost curve first, but I believe an informed, transparent, engaged discussion between the patient and the provider will, in light of clinical effectiveness research, bend the effectiveness and value curves in the right direction.

BobbyG
Guest

Yes, you’re right. See Lawrence and Lincoln Weeds’ “Medicine in Denial.”

Nice website, btw.

Davis Liu, MD
Guest

Perhaps. Though I agree that having both parties involved and likely that MDs must lead the process, there is little evidence when looking at other industries (financial / retirement planning or technology) that the public as a whole wishes to engage. What makes health care any different that the public as a whole will interact in a manner which does not exist elsewhere?

https://thehealthcareblog.com/blog/2011/03/07/why-consumer-driven-health-care-will-fail/

https://thehealthcareblog.com/blog/2011/04/15/does-america-want-apple-or-android-for-health-care/

Nate Ogden
Guest
Nate Ogden

When they are shown how it effects their pocket and it effects their pocket significantly enough they do.

I have problems getting members to change pharmacies for $5 difference in co-pays.

I have considerable luck getting them to not have that MRI outpatient at the hospital and instead go to an imaging center.

Generally we can move people from ER to UC with $50-$100 penaliy.

Despite all the claims to the contrary American’s have a lot of money to waste. If its not well over a $20 they can’t be bothered.