Cost Controls and Health Care Education

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  1. Avatar Michael Drew
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    Dan, wonderful post. Your point about not just the initial costs, but then the follow-on costs of needless tests seems very clear and consequential, at least to this lay person. I realize that the singular of anecdote is not data, so we have to take your view on the matter with a grain of… something…but I have long hoped for an opportunity to ask a physician this question: Many people suggest in the course of policy debates that the major driving force behind the epidemic(?) of over-testing that afflicts medicine right now is the overwhelming fear of baseless lawsuit. Is that your experience and if so, do you support significant tort reform? (I understand completely if you would prefer not to dip your toes in those waters in a public forum.)Report

  2. Avatar North
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    Thanks for the insights! This is an awsome post.Report

  3. Avatar Aaron
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    Back when I was a kid, or perhaps I should say even when I was a kid, our family doctor would explain to me why he was not going to prescribe medications he deemed unnecessary, in anticipation of the unfortunate expectation held by many patients that “if you go to a doctor, you should leave with a prescription.” That was fine with me.

    My daughter’s pediatrician’s office screens cases by phone, and offers an after-hours dial-a-nurse service, avoiding in-office visits for minor matters. I suspect that works pretty well at reducing the number of unnecessary office visits, and probably prevents more than a few ER visits that might otherwise occur outside of office hours.

    I suspect that distributing materials to patients would be a double-edged sword – some patients would read and consider the materials as intended, while others would become paranoid that each new symptom reflected a dread disease or worst case scenario. Also, for most households, offering the information, video and audio through an easy-to-find, well-organized website would probably work better than a mad scramble to find the DVD to try to determine if the baby’s midnight chest noises are congestion or wheezing. There already is a lot of information online, but it’s not well-vetted, well-organized, or necessarily clearly written or illustrated.Report

  4. Avatar Aaron
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    I should add one more thing: Some of my “I’m sorry to bother you, but…” calls to my daughter’s pediatrician, followed by unnecessary visits for a note, were necessitated by her preschool’s infectious disease policy – if they spotted a rash, or if a child had a fever over a specific temperature point, they wanted a doctor’s note before the child returned to school.Report

    • Avatar Mark Thompson in reply to Aaron
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      says:

      This.

      I’ve little doubt that there have been one or two occasions where my wife and I unnecessarily panicked and brought our daughter to see the pediatrician, although I think outside factors (ie, difficulty taking a full day off work combined with the fact that our pediatrician educated us well from the moment of her maternity ward visit that the best thing to do in most instances is nothing) ensure that we typically err on the side of not going to the doctor . But far more often has been the situation where our daughter gets sent home from day care with some trivial condition and won’t let her back until they’ve got some sort of doctor’s note.

      Also – add me to the chorus of voices shouting “great post.” Lots of useful info in here.Report

  5. Avatar Jason Kuznicki
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    says:

    Several scattershot points:

    –In Voltaire’s day, his claim was well-founded. Given the state of medical science back then, most patients would have been better off with a hot bath, a fresh change of clothes, and a wholesome meal, rather than with a trip to a doctor. Failing that, one of the few truly useful drugs the doctors had was opium, which neatly fits Voltaire’s prescription (to “amuse” the patient).

    –I suspect that there’s a strong generational difference in attitudes between, say, my own generation and those just a bit older. I take it for granted that there is an enormous and authoritative compendium of medical information online, and whenever I have the slightest question about my health, that’s where I go first. Seeing a doctor would mostly be a waste of time and money. Likewise I research any new prescription or diagnosis. This is the only body I’m ever going to get — if anything is important for me to understand, surely it’s this.

    –By contrast, I’ve seen people in my parents’ generation on dozens of prescriptions whose names and purposes they don’t even remember. One individual was on daily Ambien for many years — a treatment plan that nearly ruined her memory. It’s also one that she might have known to mistrust if she’d looked at the Ambien Wikipedia article. Another individual had been repeatedly prescribed the same narcotic painkiller by several different doctors in succession, and she was obediently taking many times the recommended maximum dose. No wonder they thought she had senile dementia.

    It wasn’t so long ago that no one ever questioned their doctors. Now even ordinary people, with no great level of education or native intellect, have all the tools they need at least to ask helpful questions and avoid important mistakes.

    –I read a lot about doctors’ reluctance to prescribe painkillers for fear that they will be suspected of catering to the recreational market. There’s no doubt some truth to these stories, at least for some people. But there are also clearly cases of overmedication, and judging by the experience of my extended family, these are very common too.Report

    • Avatar ThatPirateGuy in reply to Jason Kuznicki
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      says:

      When I go to the doctor I specifically ask that they not give me anti-biotics for non-bacterial infections. Anti-biotic resistance worries me as I am allergic to one of the new family of anti-biotics. If the regular ones stop working I could be in serious trouble.Report

    • Avatar Simon K in reply to Jason Kuznicki
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      says:

      “Another individual had been repeatedly prescribed the same narcotic painkiller by several different doctors in succession, and she was obediently taking many times the recommended maximum dose. No wonder they thought she had senile dementia.”

      As an immigrant from the UK, this is what particularly stuns me about the US: the total lack of true primary care. In the UK, all treatment of a patient is coordinated (and in a sense paid for) by the patient’s general practitioner. All referrals to specialists and drugs prescribed by them go through the GP. Not only does this save the unnecessary expenditures incurred when patients go to their heart specialist with indigestion, it also prevents this kind of positively harmful overtreatment.

      What puzzles me is why most insurers, with the odd exception like Kaiser that run their own hospitals, don’t insist on this. The closest my supposedly-managed health plan gets is to force me to make a 5 minute phone-call to my primary care physician if I want to go somewhere else – there’s no coordination or review of treatement at all.Report

  6. Avatar Scott
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    says:

    If you could loosen the AMA’s stranglehold, nurse practitioners could help cut costs as you don’t need a doctor for everything.Report

  7. Avatar zic
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    says:

    Great post, Dr. Summers. We have BCBS’s high deductible insurance in ME, and have actually gotten this type of information from the insurance company after filing some claims — a child with a prescription for an asthma and allergy meds resulted in a great little booklet about living with asthma.

    I don’t know if the insurance company knew an informed client would limit their costs or if it was testing the notion, since other claims, including MRI’s for chronic back problems and Migraine did not trigger a pamphlet in the mail.

    But I also agree with Aaron’s comment — sometimes, that visit is necessary to resume life after an illness.

    A good public education campaign might help bend the cost curve.Report

  8. Avatar Francis
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    says:

    Isn’t this exactly what WebMD is trying to do?Report

    • Avatar JosephFM in reply to Francis
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      says:

      No, they’re trying to make money selling ads alongside this kind of information.

      (Sorry – I have some experience working with health information sources for the Internet Public Library. We’re told to go to the NIH Medline first).Report

  9. Avatar Alan Scott
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    says:

    I work in one of those heavily unionized industries that provides great health plans (but still manages to pay terribly). One of their cost-cutting measures is a 24 hour health advice hotline–someone you call and ask “should I bother going into the doctor for this?” It’s a great way to cut down on unnecessary visits.Report

  10. Avatar steve
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    says:

    Couple of things. First, there is evidence that more utilization of primary care docs rather than going straight to specialists does reduce total spending (see Simon above who has experienced more primary care). Next, most of our spending is not on office visits. 80% of our spending is on 20% of the population. It is the big ticket items that are killing us and chronic care. In that vein, you are correct to go after testing as a primary cause of increased costs. We do way too many just in case tests.

    We also do way too many tests that increase someone’s income. Too many MRIs are owned directly or indirectly by docs who benefit from ordering them. Beyond the financial incentives, there is just practice variation. Many of us were trained to be complete and order that extra test. We need to know our data better and trust it. Lastly, it would probably help to have malpractice reform on this issue. Anyone following guidelines should not be subject to suit. Will patient education help in this arena? Maybe, but I am dubious. In blogland everyone is bright and computer literate. In the real world, the majority of my patients (I have been keeping track) who have had a heart valve replaced cannot tell me which one it was. It would take a huge cultural change to achieve some of what you suggest. We should still try, but our big cost savings are not so much in fewer primary care visits, but in reduced procedures and tests.

    SteveReport

  11. Avatar Kyle
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    says:

    A couple of perhaps ancillary points, in relation to Mark, Jason, and zic’s comments

    Beyond schools, workplaces and gyms can require a doctors notes for various issues and it’s all defensive but nonetheless is part of a culture that says it’s better to be safe than sorry, which is prudent but expensive. I do think there’s an element of responsibility in checking in with your doctor but I think the better solution is to widen the array of medical professionals who are qualified to make certain assessments and judgements.

    Second, I don’t disapprove of zic’s suggestion of (still more) public health campaigns and think there’s something to Jason’s anecdote about a shift towards more self-diagnosis and patient involvement in care. That said, the thing that enables both to be successful, is education. At the risk of a thread jack, this is one of the problems I see with looking at problems so narrowly.

    We know that illiteracy is a deterrent to seeking medical care, even when its available and hampers the ability of patients to follow a particular regimen. So our problems with public education end up acting as a drag on the efficiencies of our health care/insurance reform efforts and to no small degree vice versa.

    Dan, this is an informative and interesting post, thanks for sharing it.

    I just want to emphasize that health care education, indeed health care is not so inseparable from education at large and to the extent that we’re talking about public health campaigns and practices that rely upon the functional literacy and cognitive abilities of “the people,” we should remember that not everyone can access such seemingly basic information.Report

  12. Avatar Dan Summers
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    says:

    Just a few brief follow-up thoughts. Sorry I’m so late in posting replies — Wednesday is typically my day away from the computer.

    It’s hard to say to what degree defensive medicine contributes to unnecessary testing. If you want my personal sense, I would say “a lot,” but that’s only my impression. There’s always a lurking fear of missing that crucial diagnosis, which is then compounded by the fear of legal repercussion.

    Jason, I would concur that Voltaire’s statement was more true when he said it than today. But it’s still remarkably apt in a lot of situations.

    And there are a great many Web resources, some better than others. However, finding concise, accurate, helpful information can sometimes be very difficult. It can be thus difficult to know what to trust. Materials that bear the imprimatur of, for example, the AAP and the endorsement of one’s own doctor would presumably be preferable. And, of course, there need to be clear caveats that concerned parents should always, always be free to contact their providers if they are worried.

    Thanks for all the positive feedback, everyone. It’s always a pleasure to contribute here.Report

  13. Avatar Ross
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    says:

    Here in British Columbia we’ve got a similar thing called the BC Health Guide. It’s a good four hundred pages of things that could go wrong with you, how to prevent them, how to treat them, and how to tell when you should go to the doctor. (It’s even got a whole section on how “making wise health care decisions”). Anyone can get one for free, or call the 24-hour “NurseLine” for advice. From what I can find, the whole thing costs the government 35 million bucks a year, which is something like 0.2% of provincial health-care spending. I imagine it saves us a whole lot more.Report

  14. Avatar 10 Hr Osha Training
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    says:

    We know that illiteracy is a deterrent to seeking medical care, even when its available and hampers the ability of patients to follow a particular regimen. So our problems with public education end up acting as a drag on the efficiencies of our health care/insurance reform efforts and to no small degree vice versa.Report

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