Wednesday, April 4, 2012

The Costs of Health Care – Change Can Occur

Health care is currently undergoing much change.  Unfortunately, the care provided in the United States ranks not as high as expected given the costs.  The US health care system is the most expensive in the world.  Yes, we have amazing medical centers here, and incredible research is done here, with successes seen every day.  But, along with those successes come the harsh reality that care is uneven for the entire population, simply costs too much, and this is affecting our entire country.
Health insurance costs are through the roof.  It costs so much for a family to comfortably cover health insurance costs, as to be prohibitive for many.  Companies are struggling to be able to provide health insurance benefits to their workers and families.  Some patients choose not to have health insurance due to excessive costs.
No one REALLY knows how much specific treatments and diagnostic tests cost (and even then, the costs vary significantly from place to place).  Doctors order things every day, without understanding what the cost is to the patient and to society.  Patients get billed for many different services that they may not even be aware of (e.g., a “facility” charge, a specialist charge, an imaging charge, as well as other costs hidden until the bill arrives).
This is a problem, and it is a massive one.  But rather harping on “what is wrong with health care”, I prefer to take the high road.  I prefer to highlight solutions—and one was just rolled out earlier today.
I am talking about the Choosing Wisely campaign.  This is as good as it gets, and demonstrates that doctors and the organizations which they belong to want to try to fix some of the costs associated with care.  Specifically, this initiative is looking to focus on the “overuse” in medicine that is so common today. 
There are tests that physicians and other health care professionals order on patients which unfortunately have NOT been proven to improve care.  In fact, sometimes these tests lead to more unnecessary tests, without improving outcomes.  It is the outcomes that matter most.
The American Board of Internal Medicine Foundation (or ABIM Foundation, for short) worked with multiple medical organizations to determine 5 tests within each specialty which should NOT be ordered for common issues pertinent to that organization.  In the first roll out, announced today, 9 specialties each discussed 5 tests which should be avoided in specific, common patient care scenarios.  What a fantastic idea!!
While there may be other potential solutions for lowering the costs of health care, the reality is that it still is physicians and other health care professionals who order these tests.  If they can decrease the ordering of unnecessary tests, costs will be reduced, plain and simple.
This is NOT rationing, in my opinion.  It is simply working smarter to do things which are the right thing to do (or to avoid things which are the wrong thing to do).  It means explaining to patients that a CT scan is not necessary for that headache.  It means not ordering an MRI for that patient with low back pain who likely has a low probability of having a rare condition causing that pain.  A simply way of explaining it is "first do no harm"--what I learned on the first day of medical school is still just as important as every other thing I learned.
Please support this cause.  It is really a noble one, and should and will be promoted throughout medicine, whether it involves patients seen by primary care physicians or those seen by specialists.  What I really like is the approach to roll this out not to just the physicians and medical organizations, but to the lay public as well.  It will also be mentioned in Consumer Reports later this year.
Support the Choosing Wisely cause.  It is an example of physicians choosing to put what is right and what they can do right now to improve health care first, and their own pocketbooks second.  I know that I will put it into practice immediately, especially when seeing patients and teaching medical trainees at the point of care.
For a list of the 45 statements from the 9 organizations, click here


  1. Yes, health care is in the hands of physicians and health insurance companies. Now the government is trying to step in and be the director of health services. If you are self employed or self insured there are even greater than ever costs incurred. The cost of health care with a low deductible can be almost one week’s salary. If you carry health insurance with a high deductible to only be used for emergencies, you must pay out of pocket for everything until you reach your deductible. For example if you have a policy with a $5,000 deductible, you will probably pay for every office visit and minor injury or illness that comes along during the deductible year. Add that along with the premium for the $5,000 deductible insurance policy and the costs of self-pay and you have already blown the budget. The only alternative is to rely on charity hospitals for minor injuries or illnesses or out patient surgeries, which will be under the $5,000 but yet unaffordable by self-pay and tell them you have no insurance. Often times the charges are pro-rated depending on your financial ability to pay. You therefore end up using your insurance only for a major illness event and if you don’t have anything major, you wonder why you have the insurance in the first place. Oftentimes families that are self employed will have one of the spouses work outside of the home at a business that provides health care as a benefit; not for the income but for the health care coverage. Many businesses that should have employees are labeling their workers as 1099 workers avoiding health care benefits (not to mention other tax related costs).

    I could also go on to write and tell about incurred charges from physicians who change their mind during wellness visits and refuse to label them as such if they find out that you need a refill on a certain medication during your wellness consultation. This wellness lab work was ordered by them under the wellness provisions of insurance and then the physician turns the tables and makes you pay for it (because you are a self pay) when you only needed a refill and refused to count the lab work as your wellness visit which they wrote the prescription to the lab in the first place for wellness work. Is this a ploy to make more money on their part? Could you not have rescheduled the need for a refill with another office visit (even the same day) so that the lab work costing hundreds of dollars would stand as a wellness visit. I would gladly pay out of pocket for an office visit over hundreds for blood lab work.

    I am glad to hear that as a physician you have a conscience and are willing to work with your patients to provide excellent health care as well as looking out for their financial costs associated with their visits to you. Your patients are lucky to have someone this wise and compassionate and ethical looking out for their human
    body of anatomy .

  2. Thank you for your comments. In terms of "wellness lab work", I believe that there really is not any justification to order laboratory tests "just because". There may be certain screening tests indicated in certain populations (for example, an HIV screening test in sexually active persons, or a cholesterol level in a 43 year old male), but I am not aware of any guidelines mentioning the necessity of ordering labs in a wellness visit.
    Another example of what you are referring to involves a "screening colonoscopy", which has a certain charge. But if the physician finds something, and, for example, needs to do a biopsy, the code for doing a biopsy changes it from a "screening" to a diagnostic procedure. But that is certainly better than not doing anything, then bringing the patient back again to do another colonoscopy.
    I agree with your point that physicians need to be conscious of what they are doing and what their patients are being charged. Remember that doctors themselves are patients too. I am reminded of this every day myself when I or my family utilize the health care system.

  3. The high cost of the health care can be change in order to make certain changes in the system.This is the feature which will bring equilibrium in the society through low cost of health care.
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  4. Access to health care varies across countries, groups and individuals, largely influenced by social and economic conditions as well as the health policies in place. Countries and jurisdictions have different policies and plans in relation to the personal and population based health care goals within their societies. Thanks.
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  5. In addition, the results of health services research can lead to greater efficiency and equitable delivery of health care interventions, as advanced through the social model of health and disability, which emphasizes the societal changes that can be made to make population healthier. Thanks.
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  6. In particular, the practice of health professionals and operation of health care institutions is typically regulated by national provincial authorities through appropriate regulatory bodies for purposes of quality assurance. Thanks.

  7. I agree with all of the comments related to societal issues around health care. HSR can lead to greater efficiency, but getting that message to the "front line clinicians" is a challenge, given the firehose of "you should do this; you should do that"-information thrown at them.
    Alex Djuricich