Stories by Victor Green

Victor Green is a practicing internist.

What Doctors Don’t Know about Health Costs

April 14th, 2010 at 3:37 pm 20 Comments

As a patient you may be overdue to have a conversation with your doctor about cost control. As a physician I know that doctors face many perverse incentives and pressures that contribute to our growing medical bills. Here are four ways we can promote cost control in medicine.

1. Teach it in Medical School. Medical students are bombarded with an onslaught of medical coursework to master in a short period of time. A good doctor must learn to be clinically competent, articulate, and compassionate; but are they ever taught to be cost effective?  This aspect of medical care is so low on the priority list of learning that it simply does not get taught in a meaningful way in medical education.

The solution is to integrate the importance of cost effectiveness from the first year of school.  Students should understand the reality of what tests and procedures cost.  Students should be tested on their knowledge of how to provide the most cost effective treatment without sacrificing quality.  You may be surprised that many doctors don’t know how much the medicines they prescribe cost their patients.  You can test this: ask your doctor if he/she has any idea how much the medicines you or your family take actually cost (not just the co-pay).  Doctors are often unaware that patients are spending hundreds of dollars each month on medicine.  If you are fortunate enough to have a low co-pay, then the insurance company is picking up the tab.

2. Patients should demand affordable treatment. Doctors may realize that the cost is relevant if patients ask if they are being prescribed the cheapest and most cost effective medicines.  For example, many blood pressure medicines cost pennies a month, but doctors prescribe more expensive medications out of habit, or because the drug rep dropped off a bunch of samples. Often if a patient simply asks if a cheaper medicine is available, the doctor can actually find it.

(As a side note – drug representatives love to give out free samples. Doctors distribute them, trying to be helpful at first. However, when the samples run out, the patients end up paying the high prices for these fancy new medications instead of using cheaper older medicines that are likely just as effective).

3.  Reduce the fear of lawsuits. When doctors practice under the fear of lawsuits, it leads to frivolous testing. This is not good medical practice, but it is the reality of dealing with the fear that they will be sued if the patient does have that disease which is only remotely likely.  This results in many expensive tests with very low yield.

Similarly, there is a large subset of patients who expect antibiotics for every cold, and an EKG once a year for “good measure”. I had a very educated acquaintance once tell me he “fired” his doctor because his doctor didn’t order enough tests.  He was much happier with his new doctor who ordered many more tests and never found anything wrong. His former doctor was probably practicing not only more cost effective medicine, but more sophisticated, reasoned medicine.  The doctor who uses his brain first, rather than simply shooting from the hip, will make better decisions with fewer tests.

4. Accept Reality. Healthcare is not free so we need to seriously consider how much money a life is worth.  Every life is “priceless” in its own way, but do you want to spend hundreds of thousands of dollars on the last days of each life in the intensive care unit, knowing the outcome will be death? This should be a very public discussion, but we can’t seem to do it without invoking “death panels” and “pulling the plug on granny”.

The same must be discussed in screening guidelines.  The recent USPTF recommendation to restrict mammogram screenings to women greater than 50 years old was met with a public uproar.  However, these guidelines are the same as those used in Canada, where women are not dying any sooner from breast cancer than Americans.

If you spend the money and screen many women in their forties, you will detect a few more breast cancers, and save a few more lives, but at a high cost. By that logic, we should start screening all women with mammograms in their thirties to save just a few more lives. How much are we as a society willing to pay for this additional screening? You can reduce this further to everyday testing.  Should we as a society insist on getting an MRI of the brain for every headache?  If we accept that most headaches are benign in nature, should we sue the doctor who doesn’t order the MRI when the headache turned out to be due to a brain tumor?

I am often struck by the statement that patients really believe that “their doctor knows best.” In the realm of cost control, I really think that is a big assumption on the part of the patient.