As a primary care doctor, I live with one foot in the horse and buggy era and one in the silicon age. I spend most of my time talking to patients and wielding a stethoscope, and I also use the latest high tech gadgets. But the gadgetry is getting out of hand; its overuse threatens patients and is blowing the lid off health care costs. Here’s one example. Last week, when a patient came in complaining of a cough that had lingered longer than usual, I sent him down for a chest x-ray. The x-ray was absolutely normal to my eye, a reading confirmed by the radiologist. But he added one key phrase after the word “normal.” “Consider obtaining a CT scan.”
Now the radiation from a single chest CT is equivalent to about 500 chest x-rays, which carries a real risk of causing cancer down the road. And there’s virtually no evidence that a CT would help a patient like mine. But it would certainly benefit the radiologist. He and his colleagues are paid as piece workers – they get an additional fee for each scan they interpret. Radiologists have gotten rich (they average over $400,000 annually) by buying CT scanners, MRI machines and other high tech gadgets, and prodding other doctors to order these expensive tests. And each test breeds more tests. A tiny abnormality on one CT (and most of us have something that looks a little funny if you look hard enough), means a radiologist’s report recommending “follow-up CT in 6 months to assess progression.”
It’s not just the radiologists who work this scam. Perhaps half of the stents that cardiologists put in do patients no good at all; oncologists inflict lucrative chemotherapy on many patients who gain nothing but suffering from these potions; and orthopedists often needlessly scope knees and operate on backs. And hospitals are willing partners to these rip-offs. The useless and harmful procedures keep ORs humming and beds full of high-paying patients. It’s gadgets and procedures that bring in the big bucks.
HMOs and insurers have tried to crack down on unnecessary care. But doctors and hospitals can easily outsmart them. We manufacture the data they use to monitor us. I can always make a plausible case for an expensive test, and just try interrupting a cardiologist in the middle of a diagnostic catheterization to debate whether a stent is really needed. So insurers are turning to high deductible insurance policies in an effort to get patients to do the dirty work of limiting care. Unfortunately, the high deductibles mostly keep people away from inexpensive primary and preventive care, and do little to discourage high cost, useless procedures. Even one day in the hospital pushes most patients over their deductible, leaving them no further reason to economize.
As Milton Roemer (a distinguished health policy professor) once observed: “an empty hospital bed will soon be filled.” He probably would have added “an idle CT scanner will soon be in use,” but CTs hadn’t been invented yet. Once you build it, they will come – encouraged by their doctors – and costs will rise.
So what are the implications of all this for health reform? Not good. Almost everywhere you look, hospitals are building, and the new buildings won’t house psychiatrists or family doctors who devote their days to the routine, inexpensive care that has the biggest impact on health and wellness. They’re for big ticket items like surgery and imaging suites. Those buildings will soon be filled, driving health costs further skyward. And legislation encouraging prevention, or electronic medical records, or even banning drug company gifts won’t make a whit of difference (even though I favor all of these things).
What can help? Real health planning, which limits the supply of expensive gadgets and ORs. Paying doctors on salaries rather than as piece workers. And a ban on for-profit medicine. Unfortunately, all of these require far more radical reform than Chapter 58. They’re only feasible under a real national health insurance program.
David Himmelstein
Associate Professor of Medicine at Harvard Medical School
and Co-Founder of Physicians for a National Health Program
[...] a vocal advocate of the single payer system. However, after reading his CommonHealth blog entry, it is clear that Dr. Himmelstein and I agree on at least two fundamental issues that have the [...]
This comment rightly points to some of the most important and disturbing trends in health services and clinical medicine in the United States. Costs are rising unsustainably. Expensive new technology and drugs driven by companies’ and sometimes physicians’ pursuit of profit often above and beyond the best clinical evidence are skewing resources and eroding the basic foundation of any good health care system – which must include well funded, high quality primary care services, preventative medicine, efficiency through economies of scales and investments in public health.
It was interesting, therefore, that when working as an activist and researcher trying to get improved HIV care in underfunded public hospitals in Central America, the Caribbean, or in India, I often found myself on the other side of this important debate. I and others, particularly people living with HIV and some physicians, were the ones demanding better access to very costly, but also lifesaving medicines. Later, once antiretroviral medicines became more widely available, we petitioned for hospitals and governments to urgently provide less toxic and more tolerable but more expensive second-line drugs, administer improved access to viral load tests, and better monitoring of CD4 counts, all of which were costly, but have become standard in HIV care in the United States and most developed countries. We also raised demands for the introduction of new technology for expensive genotype and phenotype tests to better identify and track drug resistance. Such drugs, tests, systems, and technologies could significantly improve individual clinical management for people living with HIV/AIDS as well as the government’s drug resistance and treatment surveillance efforts which are critical to the lives of millions and the battle against the AIDS epidemic, but most are too expensive and are often priced well beyond the budgets of health ministries in resource poor settings.
In each instance we knew that demands for more costly technology and drugs would be met with considerable and perhaps, in theory, also prudent and reasonable resistance by cash strapped governments and health systems, which were failing to provide even the most basic health services to the population, let alone advanced and expensive care for people living with HIV/AIDS. Yet from a human rights perspective, people with AIDS were needlessly dying and receiving substandard care.
Rationing and efficient planning will likely be needed improve coverage and costs and health outcomes and reduce disparities in the US health care system. However, even before this would be necessary, restructuring physician’s salaries, the pharmaceutical industry, and the medical devices market, could prove much less painful and more efficient to the majority of patients. How health services are structured, how the latest and best technology and how innovation is driven and paid for, and how such technology is utilized, are essential areas where the market and status quo, particularly in the United States, has been unable to provide the best solutions. Substantial changes are absolutely essential. Sometimes, more technology and medicines will be needed, and such tools, in addition to more cost effective, evidence based primary care must be made more widely available and affordable to those who need them, not just in the United States but also worldwide, where the needs are greater and the resources far fewer.
Eugene Schiff
Tufts MD/MPH Candidate
Many pediatricians like me have long felt that the “cognitive” specialties (such as primary care, psychiatry, preventive medicine, developmental pediatrics) are grossly undervalued compared to the “procedural” specialties like radiology and orthopaedic surgery.
Dr. Himmelstein offers “a ban on for-profit medicine” as part of a solution. However, simply adjusting the current RBRVS system would drive change in the right direction. Incentivize physicians for choosing primary care specialties; pay doctors more for talking longer with their patients, rather than ordering more tests; reduce the RVU conversion factor for overutilized procedures; and add RVUs for coordination of care and medical home oversight, which pediatricians have been doing long before it was trendy or recognized as actual “work.”
Physicians bill for procedures because they are more lucrative than cognitive tasks. However, invert the current skewed pyramidal fee schedule, and watch med students flock to primary care again. As Dr. Himmelstein points out, once you build it, they will come.
Suzanne Berman, MD, FAAP
Crossville, Tennessee