Cost Controls and Health Care Education

by: Dan Summers

“The art of medicine consists of amusing the patient while nature cures the disease.” — Voltaire

While reading Jason’s predictions about the health care reform bill, I was struck by one of the comments. Commenter A. R. Yngve wrote,

My dad was a physician (the “general practitioner” sort) in Sweden.

Toward the end of his life, he collaborated on a thick booklet titled “Self-Care” which was sent out for free to I don’t know how many people in his administrative region (Sweden has both regional and municipal administrative regions for public health care).
…

The purpose of “Self-Care” was prevention: to educate the public about various common afflictions and infections, how to identify symptoms on your own, and how to prevent ill health, infection and injury.

This got me thinking. As a purely speculative exercise, I wonder how and if a similar program might work in the United States.

The simple truth is, at least in the case of pediatrics (my specialty), patients are frequently brought in for illnesses that do not require evaluation by a medical provider. While it’s nice for parents to be reassured that their children are basically well when they’re going through one of childhood’s myriad contagious illnesses, from a cost-benefit perspective many of those visits are hard to justify. I imagine that this is true for other health care providers, not only in primary care settings, but also in emergency departments and urgent care clinics.The most common example is the viral upper respiratory infection, or cold. For the overwhelming majority of patients who present with this complaint, there is little that can be done other than supportive care. In other words, I can’t fix a cough, runny nose or chest congestion. To concerned or exhausted parents this can be frustrating news, particularly as over-the-counter cough and cold medications aren’t recommended for young children. And I share their frustration that there is no meaningful intervention to be offered other than reassurance. But the reality is that most of those patients could get by without my seeing them, and without incurring the costs of the office visit.

I laud the President and Congress for trying to correct many of the worst problems regarding health care coverage (I am generally supportive of the current health care legislation), but I also agree that there needs to be more attention paid to issues of cost containment. It is great to increase access to health care for those who need it, but over-utilization is a very real problem. One step in the right direction would be to give patients and parents more information about the kinds of things that could safely and appropriately be monitored at home, and what really calls for a trip to see the doctor.

What might this look like?

I would suggest a series of easy-to-understand books for distribution at routine well child visits and physical exams, starting at six months of age and continuing through adulthood. (Infants under six months should generally be evaluated when they are ill, due to the higher risk of complications from even common illnesses.) It would make sense to distribute the materials I suggest at these visits, because they’re both a point at which patients are expected to show up at a specific time in their lives (and thus materials can be tailored to the right age) and parents expect to get information about health maintenance.

Topics for children should include upper respiratory tract infections, uncomplicated fevers, viral gastroenteritis (aka “stomach flu”), and some common rashes, and I’m sure any decent internist could draw up a similar list for adult patients. They should be clearly illustrated, and have useful information about symptomatic management at home. And they should help parents determine what signs (eg. lethargy, dehydration, increased work of breathing) are indications that their children really should be seen. One useful tip – if your child is well enough to merrily destroy my exam room during his visit, he’s probably well enough to stay home.

Ideally, multi-media resources (web pages, DVDs) would also be available to help with symptoms that are hard to describe verbally. For example, it can be difficult to differentiate between chest congestion (which doesn’t typically need to be evaluated) and wheezing (which does). Audio of the different sounds could help parents feel more confident in their ability to triage their own kids’ needs, and keep them from the inconvenience and cost of schlepping them in for unnecessary care.

If I’m going to create a wish list, I may as well also include information about over-testing and over-treating. There is a pervasive, commonly-encountered belief among patients (and, frankly, too many doctors) that there is some kind of value in ordering tests “just in case.” Testing in the absence of a particular clinical question to be answered generally yields useless information, or worse.

Every test ordered increases the risk of an erroneous result, which will then require its own round of follow-up testing to rule out some associated disorder. X-rays and CT scans confer the additional risk of radiation exposure. And that’s to say nothing of the monetary cost. If more patients understood that they were not being short-changed by a doctor who declined to order tests for their own sake, I am confident it would lead to a decline in the costs of health care overall.

In a similar vein, nobody is served well when prescriptions are doled out in attempts to placate demanding patients. I will readily admit that most of the onus for this problem falls on providers. It is much easier to scribble out a prescription for Zithromax than to explain to a disgruntled patient that her symptoms are viral, and will simply resolve with time. Doing so is wrong, regardless.

However, if more patients understood the natural progression of illness and some common myths were debunked (green nasal discharge = sinus infection, for one) it would take some of the pressure off, and might prevent a few repeat visits when the cough hasn’t gotten better in two days. After all, those “frequent flier” visits add up over time, and we all end up sharing in the cost.

I hasten to repeat that all of this is purely speculative on my part. These ideas are based entirely on my observations as a pediatrician after having worked both in large metropolitan medical centers and small rural hospitals. I have no data to support that a program of patient education will effect a reduction in health care costs. However, I can state with confidence that over-utilization of health care resources is a real problem, and proper patient education is one common sense approach to the problem.

In order for this to be effective, it would require a significant degree of buy-in on the part of patients and their families. As sure as the sun rises, any effort on the part of the Obama administration to increase patient education about proper utilization of resources will be met with criticism by some that this is an attempt by the government to deprive families of access to needed services, to ration care a la those infamous “death panel” assertions.

On an individual level, no matter how comprehensive and well-written educational materials may be, particularly anxious patients and parents will still opt for office visits (or, worse, trips to the emergency department) for common, benign ailments. And alarmist or venal providers will still recommend patients be seen for minor complaints.

It is that last concern that I think makes a program of this kind unlikely to ever become a reality. To put it bluntly, I have a hard time believing that the American Medical Association (of which I am not a member) would ever let this happen. Fewer patient visits mean lower income for doctors, and this kind of “bread and butter” visit shores up a lot of physician incomes (including mine). The AMA is about nothing so much as protecting physician pay, and any threat to it would be met with vigorous opposition.

If we are serious about controlling health care costs, we have to take an honest look at what we are spending our money on. A truly discriminating analysis cannot fail to uncover a great deal of unnecessary care, starting with visits that never had to happen in the first place. If a program of public education about how to avoid needless trips to the doctor’s office can lower costs for everyone, it’s a program I would gladly support, even if few of my fellow physicians were to do so.