McNutt-Hadler Credo for Value-Laden Medical Decision Making

Robert McNutt and Nortin  Hadler respond to med student Karan Chhabra’s  original post,  “Actually, High Tech Imaging Can Be High Value Medicine” and the resulting discussion thread.

Thank you for your comments. First, we are happy you are so interested in medical practice and how to do it better. Please do not think for one second that our comments are critical of you.

However, since you persist in thinking that money matters, that you have the right to think that way during your care of a patient, and that economic principles help patients, let’s look again at this issue you have raised.

Nearly 20 years ago, Hadler published his first “Four Laws of Therapeutic Dynamics” (JOEM 1997; 39:295-8):

1) .    The Death Rate is One per Person

2) .    Never Poke a Skunk

3) .   There has Never been a Quack without a Theory

4) .   Institutions Die; People Live

Now we present, for the first time ever, the econometric corollaries, the McNutt-Hadler Credo for Value-laden Medical Decision Making:

1) Don’t think of money; think of what the money buys. No patient should be offered a pig-in-a-poke.

2) Don’t think for one moment that medical pricing is rational, let alone market driven. Medical pricing is designed to serve the greed of stakeholders, greed that seems to know no ethical boundaries. Caveat emptor is no match for “common practice” The only way the “consumer” stands a chance is if there are physicians committed to explaining the basis for clinical decisions in an unbiased, transparent, and ethical fashion.

3) If it doesn’t benefit the patient, we don’t care if they give it away – don’t prescribe or order it. (For example, no stable in-patient should have any of the following tests: amylase or lipase; any test for iron deficiency other than the ferritin; CRP, BNP, MRI after a CT of the head, or any chronic care medicine like a statin, iron tablet, heart healthy diet in a cancer patient, vitamin, a blood pressure medicine that costs more than the cheapest alternative, a non-generic medicine that is available in generic form, enteric coated aspirin, or bone scans in women looking for osteoporosis)

4) If it doesn’t benefit the patient, and the patient still wants it, we shouldn’t share the cost. If it’s useless but not harmful, the expense should be assumed by the patient. If it’s useless but harmful, it should not be available.

5) If it is relatively beneficial, the patient should be offered an opportunity to apply personal values and risk aversion to the clinical decision.

6) Spend anything it takes to save a life only if it is proven that it does. Dying in American should not be a profit center.

7)  Do not let money influence decisions; avoid any conflict of interest; including going into a branch of medicine that forces you to make decisions that may be more gainful for you than for your patients; be financially neutral and patient oriented only. Better to starve than to knowingly disserve. Personal gain is no substitute for self-respect. Faust understood this.

As a physician, find every source of waste and discard it with your patient’s blessing. Know that much of “common practice” is not helpful for individual patients; that much of clinical evidence, particularly for small effects, is unreliable; and that to be a physician demands the highest standards of professionalism – economics be damned.

What we can do to help patients with the high cost of care is to stop using care that doesn’t matter, and making sure we spend what we must to help them when we know how to.

Without such a Credo, health is a commodity, diseases a product line, and physicians a sales force. We need a new generation of physicians to pull all of us back from this brink.

Robert McNutt, MD has been an associate editor at the Journal of the American Medical Association for 12 years and before associate editor at the Journal of General Internal Medicine. He is a professor of Medicine at the University of Wisconsin and Rush University Medical Center.

Nortin M. Hadler, MD is a graduate of Yale College and Harvard Medical School. He joined the faculty of the University of North Carolina in 1973 and has been a professor of medicine and microbioogy/immunology since 1985. His assaults on medicalization and overtreatment appear in many editorials and commentaries and 5 recent monographs: The Last Well Person (MQUP 2004) and UNC Press’ Worried Sick (2008), Stabbed in the Back(2009), Rethinking Aging (2011) and most recently, Citizen Patient (2013).

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25 replies »

  1. ウエスト部分がキュット絞まっているので、入るかなーと不安でしたが、伸縮性がありいい感じのフィット感でした。試してみて良かったらリピ買いします☆

  2. You are putting too much responsibility upon the doctor for cost control. Unfortunately, he works in an expensive shop, where 1/7 of the population is trying to make a living.

    I recall a young woman coming to our ER trying to find if she was pregnant. They had to assign an outpatient room to her and a physician. There was some work-up required. I recall that my lab’s Gravindex test was $2.60 because I had just talked to the tech who had reordered it. This test looks for urinary gonadotropin levels. It is up in pregnancy.

    I saw this woman’s bill later–she was startled and came to the lab to see me–and the hospital had charged her $119.00…. Just to tell her whether we was pregnant or not.

    Try to visualize stakeholders upon stakeholders all in a long line going up Mt. Everest. The climbers are the docs and nurses. The remainder are the porters.
    Big problem : the porters have to eat also.

    Of course this was in the days of yore and prices were different. The point is: prices are killing us. Nothing will work with these prices. There are only two ways to get them down: competition and monopsonic purchasing. The government will not do the latter. Big political donors are not expected to bargain with massive purchasers.We needed ingenious ideas from the ACA.
    Zip came. We need to whet every idea about sharpening competition. Competition between plans, between hospitals, between pharmacy benefit managers, between pharma, between doctors, between factors of labor, between hospital suppliers, between managers. Prices must come down to some realistic approximation to costs and costs must come down to approximate factor costs of getting the medical output accomplished.

    No one is going to participate in any health system if they cannot afford it. The actual cost of most lab work is pennies–I am a retired pathologist and have directed many laboratories–and we must prevent hospitals from using labs as profit centers. Lab tests are usually quite safe and give us many clues. You say don’t do serum irons. Don’t you want to ever diagnose hemochromatosis? It’s a very common inherited disease.

    Anyway, I’m not alarmed with your analysis…only asking folks to be attempting to bring down all costs and prices as they are the viscous glue that keeps us from succeeding with any health system.

  3. Just in case it was misinterpreted: the comment I posted above was facetious. The point is that all these (mostly non profit) experts have led us to a totally messed up cost and pricing system…..and in my opinion this history should lead us to massive doubt that the new fads and systems these same players are designing to fix the problem (ACOs’, sticks and carrots based on “quality” metrics, medical home, electronic health records)….all of which cost billions to implement…..will fix the problem.

    Furthermore, I submit that the modest decleration in medical costs over the last decade is almost entirely attributable to the slow and steady growth of high deductible plans linked to health savings account as well as employer plans adopting higher co pays and deductibles….meaning that the patient has an increased incentive to make consumption and value choices re their medical service utilization (even as this remains difficult in this messed up pricing system).

  4. The fact that pricing is neither transparent nor rational is one of many reproaches to the American “health” care system. The only rational solution is rational reform. However, there are temporizing measures.

    I recently reviewed a pair of books for the Journal of Occupational and Environmental Medicine (the review should appear in the next month or two.) One, “Cracking Health Costs” (Wiley, 2013) is written by Tom Emerick and Al Lewis. Tom Emerick is a highly experienced benefits manager, now a consultant, who pioneered competitive pricing for corporations that self-insure. He finds it much cheaper to fly an employee (and spouse) to the more competitive provider even if it’s in another state.

    This may make good business sense without compromising care, but I view it as yet another condemnation of the American “health” care system.

  5. Yes, much like Expedia or one of those sites. If providers (docs, hospitals, imaging centers, etc.) know they will be chosen in terms of price as well as quality, we may start to get some reasonable rates for health care.
    My assumption is that with the higher deductibles in Obamacare, many more will be paying out of pocket for certain things and should be able to compare prices.

  6. @Perry
    How about if we reveal all health-care prices?
    There’s really no good argument for all the secrecy.
    Then once the prices come out of the shadows, what must follow is real, actionable quality metrics.
    This will happen — it’s only a matter of time. Anything we can do to bring price out of the shadows is a good practical first step.
    If you’re a provider, make your cash or self-pay prices public.
    If you’re a payer, make your reimbursement rates public.
    If you’re a patient, make public what you were charged, what the insurance company paid, and what you paid.
    We learned a lot when we crowdsourced the price of mammograms with WNYC here in NYC — expect to see us doing more of the same!

  7. @Dr. McNutt,
    “But, then, we present the patient the overinflated, nonsense cost based on profit rather than value,”

    Why is that cost so inflated? If you go to buy a car, do you get it at the first dealership you visit, or do you shop around for a deal? While cars are certainly not cheap, there are deals to be had, because the market is competitive. Not so in health care. My question is how can we inspire competitiveness and consumerism in health care, other than having insurance companies make secret behind-the-door deals, and patient still not knowing the cost?

  8. I am not sure that anyone in control of medicare or insurance or medical leadership is hell bent to change the system. The leaders in charge are conflicted; the AMA itself has a hand in setting inflated, subspecialty advantaged prices and owns the patent on the CPT codes. Take a look to see who is on the medicare governing board; looks like a who’s who in business. Those in charge are not regulating our common good; they are piling more or their “cows” on the common feeding ground; our patients.

    Perry seems to say that there is no consequence to care as cost is hidden. I agree. The only way to regulate a common good is limits and consequences. However, I am not sure, Perry, that transparency of cost will help. Think for a moment; suppose a patient would say that a 5% increase chance of living longer over 10 years is worth the risk of treatment. They make the decision based on best-evidence. But, then, we present the patient the overinflated, nonsense cost based on profit rather than value, and the patient is scared off. The cost/charge part of the equation is so out of whack that I worry about the bias it produces. Just presenting the value to a patient may be enough to change our medical care from system-down to patient-up.

    Which leads me to remind; I wrote item number 1 as number 1 for a reason. I repeated it at the end to make a point but my wonderful co-author thought it redundant. But, I say it again. Don’t think of money; think of the medicine; think of the benefit and the risk and don’t spend for nothing. There are so many “nothings” out there that we would have plenty in the bank for things that matter is we would just have the courage to do so. Our problem is that we don’t yet agree that money doesn’t matter; and I think that does a disservice to our ill patients.

  9. How can it be that medical pricing is messed up? It is set by our best and brightest experts in their fields: government experts, hospital administrators, committes of doctors, and experts in insurance company’s that tell us they are great in getting discounts. All of these highly educated folks….most of whom are working in non profits….it must be we just don’t appreciate how great our medical pricing system is.

  10. Very well said. Thank you for writing this.

    “Don’t think for one moment that medical pricing is rational, let alone market driven.”

    People ask us that all the time: when we reveal that a simple MRI can cost from $300 to $6,200, they want us to know that the more expensive one must be better. To educate people that this is not so turns out to be a heavy lift.

    And then there’s the question of whether that MRI is necessary in the first place.

    (insert heavy sigh)

    Thank you again for writing this.

  11. As physicians have the responsibility for and are rewarded for guiding our patients in obtaining the best health care they can have. To this end I believe we should be treating each of them as a beloved member of our own family with the added consideration that we consider everything we recommend was being paid by ourselves out of our own pocket. This at least should be the basis of our guidance and I do not feel it is the way we practice. Our patients die in ICUs with a tube in every bodily orifice we and our loved ones do not.

  12. Your words, “Without such a Credo, health is a commodity, diseases a product line, and physicians a sales force. We need a new generation of physicians to pull all of us back from this brink”, describe very well the state of health care today. Health CARE is indeed a commodity, diseases are often brought to the public’s attention only to promote drug sales, and physicians are indeed pressured to case-find ailments now elevated to disease status in order to find more customers for drugs that treat them – from overactive bladder to indigestion to high cholesterol. We ARE on the brink, and we need all of us to critically assess what we are doing. In hoping for a new generation of physicians to save health care, you shouldn’t forget to include your contemporaries and older physicians who remember what things were like before the “cultural revolution” brought to us by Big Pharma and the insurance companies.

  13. “All we can do today is try to establish an empathic therapeutic relationship so that patient and physician can collaborate to do the best they can.”

    At this point in our current system, I would agree Dr. Hadler.

  14. Yes, the American approach to “health” insurance is both perverse and iatrogenic and will remain so despite the ACA. All we can do today is try to establish an empathic therapeutic relationship so that patient and physician can collaborate to do the best they can. Such a relationship is exceedingly difficult to establish if the patient is a “claimant” for the provision of care, particularly if the care is indemnified by Workers’ Compensation or otherwise involves a disability claim.

    It need not be so. But that would require a general appreciation of the difference between rational and rationing. I spoke to this in an earlier post on THCB:

  15. Dr. McNutt,

    I have read 2 of Dr. Hadler’s books and greatly enjoyed them. “Stabbed in the Back” is a very interesting look at back pain and how we’ve medicalized that very common condtion in this country. Since I do Occupational Medicine, as you might expect, back pain is a significant part of my practice. In terms of patient financial responsibility, it amazes me how quickly some patients want an MRI for back pain if they believe Worker’s Compensation will foot the bill. On the other hand, if their claim is being potentially denied, they will wait until it is approved to have the test done.
    This goes back to my original posting, in that if patients have a direct involvement in the payment of their medical care, they are likely to be much better stewards of where and how the money is spent. For some reason we have continued to insulate patient and physician from cost and consequence, while putting barriers to reasonable medical recommendations and punishment for “too much” care. Third party payers control the reigns for test ordering and treatments, forcing doctors to submit mounds of paperwork to justify them.
    In the current health care/insurance situation, I don’t know if there is any way the patient and physician can return to a collaborative situation.

  16. I suggest #6 should be elevated to #1. Dying should not be a profit center! Thank you. You’ve improved my Friday.

  17. Love the comments; interesting to think about the comments regarding no-one bearing consequences of finances – physicians or patients. Will think more about that one and comment later, but comment seems insightful in the context of the “tragedy of the commons” in medical care (the commons being an ill patient).

    I also take the comments regarding spending and “proven”, seriously. If I could, might have written that bullet point differently; our point; don’t worry about money at all; if it works for the patient – spend it. But, if it doesn’t, don’t spend a dime. Hence, money, per se, is never a reason to adjudicate care.

    In terms of “proof”, we do know those situations where a life is on the line. In those situations, never short change a patient for some idea of “cost-effective” care; give them the best care regardless of cost.

  18. It is a pleasure to have you in the choir.
    That’s why Bob and I wrote this and other posts on THCB.
    That’s why I’ve written the past 5 books with 2 more to come.
    That’s the point of other essays I’ve posted elsewhere:



    We’re growing the choir.
    Now we need to fill the pews.

  19. “Spend anything it takes to save a life only if it is proven that it does.”

    Of course, that assumes what is known ex post is available ex ante. Sadly, in the fog of medicine, as in the fog of war, this roaring rip tide of a slogan becomes ineffectual when it encounters the rocky coast of reality.

  20. Let’s say I was perfectly satisfied with my car, but then I hit a Chicago pothole. When I take my car to the mechanic, my goal would be to fix the car –without having extra tests or enhancements performed.

    I’d like to be informed of the path for analyzing and fixing the problem. If this sort of problem has been dealt with before, then the path (and price) should be known.

    If there are more unknowns and obstacles than usual (and my car is the test subject), then I would want to be an involved and informed lab partner.

    Medical problems can be much more involved than car problems for various reasons: A car owner can get a new car (a patient has only one life); Biological systems have developed over millions of years (the car was born in 1886); Information overload from the healthcare industry (a car has a manual), etc.

    However, even given the complexity of medicine, a doctor cannot hide behind it. A doctor (even more so than a mechanic) must provide the due care and diligence, and convey this to the patient to earn the patients trust and to live in good conscience.

  21. It’s interesting how third party payment/intervention disrupts reasonable thinking on cost and spending. Many patients have the idea that if they’re not paying for it, who cares if it’s not helpful or not recommended. Conversely, doctors figure the patients arenot paying directly, so why not do a little extra, tregardless of meaningfulness or cost.
    When the burden of payment is on the patient, and the physician has to explain the benefits/risks/costs to the patient, both will have “skin in the game” and maybe encourage real meaningful healthcare.