A must read for all concerned with rising healthcare cost is Atul Gawande’s article in the May 11th New Yorker, “Overkill”. In this lengthy but readable review, Dr Gawande, a surgeon at The Brigham and Woman’s Hospital discusses how “an avalanche of unnecessary medical care is harming patients physically and financially.”
He uses personal experience and observations to show how, through either “upselling” or over-testing the medical community is exposing patients to iatrogenic risk and financial hardship. He goes on to state that “virtually every family in the country…has been subject to over-testing or over-treating.” This has been called “low value care.” We have all seen this in action. We have all had experiences such as “it’s probably nothing but let’s get a MRI to be sure” or “you know, the lab value is border-line so let’s repeat just to be sure.” Physicians have a tendency to make sure, as best they can, that all is correct. They also may have a leaning to “upsell” through habit. This behavior does not is not necessarily demean their ethical standards but more is a reflection of their training and beliefs.
A Reflection of the Culture At Large
These tendencies of upselling and over-testing are also part of our culture. We as patients demand the latest and the shiniest. We demand certainty in a discipline where certainty is an oxymoron. What is normal and what is non-normal? Many times it’s a patient-by-patient variable. But the non-normal test result can feed a frenzy of further testing. The same is true for biopsies. A “positive” biopsy identifying neoplastic cells can result an avalanche of cancer fear-related procedures. Hence patient behavior synergizes with physician behavior to drive “low value care.”
Lastly, as Dr. Gawande points out, the reimbursement schemes now employed by payors may even reward this type of behavior.
So what are we to do? Well… Accountable Care Organizations, medical home based care delivery, and other pay for performance programs will go a long way, but I believe we really need a cultural shift in our thinking. More does not always mean better—especially in medicine, where more can result in more risk and more money. Healthcare has to continue to identify “best practices.” Payors have to continue to develop incentives for providers to conform to best practices. And patients and their caregivers need to ask what improved outcome will result from additional testing and procedures.
I want to leave you with something I once heard Don Berwick say: “The best care is the most cost-effective care and the most cost-effective care is the best care.” I may be paraphrasing him—deteriorating synapses, you know—but the thought is true. Note he didn’t say the most expensive care, merely the best care. Ask your healthcare providers if the care suggested is the best way to go. And if they say yes… ask why.