Regardless of what your stance is on the current healthcare debate in the U.S., I think the following report, produced by NPR's "All Things Considered," requires a listen.
The Telltale Wombs of Lewistion, Maine
Note: I don't want this thread to turn into a debate about single payer heathcare plans. I also don't want it to turn into a debate about President Obama's proposals for a public option. This thread is dedicated solely to the discussion of waste in the current U.S. healthcare system, whether doctors should be paid on a fee-for-service basis, and/or whether the legislation currently being debated by the two houses can help prevent the kinds of unnecessary procedures mentioned in this report. If you want to debate single payer options, or President Obama's proposed public option, kindly take it somewhere else. Thanks.
Additional Note: Try to keep the discussion civil. :)
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I found two passages in the article that really made me confused about the conclusion that it is is doctor driven waste that is the problem.
Doctors exist in a fee-for-service system that encourages — and really because of the threat of malpractice and having to battle insurance companies — in some ways actually forces them to do more. More surgery. More tests. More of everything.
One reason some doctors mentioned was fear of lawsuits; some worried that if they didn't do every possible thing they might get sued. Another reason was temperament — some doctors were clearly just more eager to take action than others.
Then there was the role of local medical culture. For example, even though it didn't make sense and wasted a lot of time and money, pediatricians in some communities felt they absolutely positively had to send even mildly sick kids to the hospital.
"Families in small Maine communities were used to the fact that if their kid had a temperature of 102 and was vomiting, that kid was going into the hospital," says Keller. "They'd been doing it for years, so they'd be aghast if they took little Tommy down and he had a temperature of 102 and the doctor said, 'Well, go home and take this.' Nobody did that!"
It was probably safer and better all around not to put the kids in the hospital, and the doctors knew this. But doctors, like the rest of us, are people, and therefore are subject to subtle influences.
See, these these two passages, particularly the highlighted passages, indicate to me that doctors are responding to external forces when making their decisions. I've heard a lot of doctors talk about having to practice "defensive medicine." They do procedures that they know might not need to simply because if they don't they are afraid they might get sued.
Other times they just need to be sure that the diagnosis they have made was correct. For example, a little less than two years ago I went to the Emergency Room because I was having serious abdominal pain. The doctor was pretty sure I had kidney stones. The blood tests didn't show any sign of anything else, no infections, no elevated white blood cell count, or anything like that. But there were just enough rare conditions that wouldn't show up with blood tests that he decided to send me for an MRI, just to be sure. It turns out that yes I just had kidney stones, but the possibility existed that something else was wrong and if he made the wrong call, the resuts could have been disaterous.
With so many variables involved, from the doctor's personality, to the patients, from the medical culture to the threat of malpractice, I don't think it is possible to point a finger and say doctors or the for fee system are the root causes. Like my grandmother used to tell me, when you point a finger at someone, three more point back at you.
I suspect that fee for service abuse was less of an issues when more people paid for fees out of pocket. I think that the third party payment system is one of the principal contributors to escalating prices. How often do patients question the cost or necessity of medical proceedures that they aren't paying for directly?
With so many variables involved, from the doctor's personality, to the patients, from the medical culture to the threat of malpractice, I don't think it is possible to point a finger and say doctors or the for fee system are the root causes. Like my grandmother used to tell me, when you point a finger at someone, three more point back at you.
I can respect that opinion, and I don't necessarily disagree with it entirely. However, while I don't think all cautionary procedures (like the MRI you mentioned) are wasteful and/or unnecessary, I do think there are many times where they are.
I read an article in the New York Times, called "The Cost Conundrum." The article compares hospitals in two different counties in Texas: McCallen, and El Paso. Despite the fact that healthcare costs in McCallen are some of the highest in the nation, the health of patients is actually worse than that of patients in El Paso. This, in spite of the fact that the demographics of patients, and the medical equipment provided in both hospitals are roughly the same. Why the difference in health? Well, it largely has to do with the unnecessary, invasive medical procedures
Returning to the original report mentioned, I know at least three people who have had the back surgery medical procedure mentioned. Out of those three, two of them are in constant pain as a result of it. I can also tell you that none of them were ever told about a less invasive version. I'm not a doctor, and I don't know enough about the two procedures, or the medical symptoms of the people I know. However, in light of this report, and the article mentioned above, it makes me wonder whether or not they could have benefitted from the less invasive medical procedure, and if they would be in better health today as a result of it.
I suspect that fee for service abuse was less of an issues when more people paid for fees out of pocket. I think that the third party payment system is one of the principal contributors to escalating prices. How often do patients question the cost or necessity of medical proceedures that they aren't paying for directly?
My dad told me a story about when I was born. Apparently, back in the day, hospitals actually charged patients less if they paid out of pocket then if they had insurance. It was so much less that if my dad had actually paid the out of pocket expenses for my mom's pregnancy, he would have paid less than he wound up paying for his insurance. That doesn't happen today. In fact, patients who pay their expenses out of pocket typically wind up paying more, because insurance companies have the power to negotiate down the price.
I suspect that fee for service abuse was less of an issues when more people paid for fees out of pocket. I think that the third party payment system is one of the principal contributors to escalating prices. How often do patients question the cost or necessity of medical proceedures that they aren't paying for directly?My dad told me a story about when I was born. Apparently, back in the day, hospitals actually charged patients less if they paid out of pocket then if they had insurance. It was so much less that if my dad had actually paid the out of pocket expenses for my mom's pregnancy, he would have paid less than he wound up paying for his insurance. That doesn't happen today. In fact, patients who pay their expenses out of pocket typically wind up paying more, because insurance companies have the power to negotiate down the price.
In my experience here in Colorado if you let many of the practitioners know that you are paying cash you can get up to half off in some cases. I haven't seen this with hospitals however.
In my experience here in Colorado if you let many of the practitioners know that you are paying cash you can get up to half off in some cases. I haven't seen this with hospitals however.
I haven't tried it, but I'm pretty sure that's not the case in California.
In my experience here in Colorado if you let many of the practitioners know that you are paying cash you can get up to half off in some cases. I haven't seen this with hospitals however.I haven't tried it, but I'm pretty sure that's not the case in California.
It may well be illegal in some jurisdictions as a result of case law or black letter law. I see a difference in how patients and staffers behave when paying out of pocket. I don't think doctors are much different than the rest of us. They don't feel bad about charging some massive faceless bureaucracy (government or private) for a few "extra" tests, but that's a harder thing to do to a real person in your office. Like wise when we have to pay for a prescription out of pocket we are more likely to find out what the cheapest option is. People tend to care a lot less if someone else is picking up the tab.
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In the end, it's something called "The Appeal to Probability", but it's heightened because there are lives and money at stake.
The Appeal to Probability works like this:
They know that doing additional testing can cause harm, but they all know the horror stories about "the kid who I should have tested for XX but the tests were negative". Heck, the show House is based on that idea alone. David Fryer above mentions it happened to him once and was beneficial. I can mention that it happened to me twice, also beneficial each time.
The few positive stories aside, treating people comes down to the sad fact that the tests always have some probability of failing. And when it fails, people sue you or die or are in pain or at the very least you're ability is questioned.
So instead of thinking "this test works 70% of the time, it must be right", they think "this test fails 30% of the time, I better run another". They start to think of Murphy's Law, and you end up with more and more tests, until finally they have a low enough probability to feel fine about realeasing you. Some tests cause damage, but that is weighed against the possible damage that could have happened.
Add onto that fact that additional money is paid out for additional tests and you have extra tests and some discomfort is swept under the rug.
EDIT: Please note I didn't explain the Appeal to Probability outside of the context of this situation.
The few positive stories aside, treating people comes down to the sad fact that the tests always have some probability of failing. And when it fails, people sue you or die or are in pain or at the very least you're ability is questioned.
I think you're right, and that this can be a contributing factor. It's similar to the story in that report about the doctor who sends his patients to the hospital when they have a 102 degree fever. It's not because they need it. It's because the doctor believes (rightly or not) that the patients expect it.
Of course, I'm not sure how much of a factor it is. For example, I've heard reports that malpractice suits against doctors only account for approximately 2%-10% of our healthcare costs. Nevertheless, I can see how the fear of litigation might cause some doctors to prescribe additional procedures, even if the actual threat of litigation is comparatively small.
Here's a related question. Do you think Obama's proposal to limit malpractice suits against doctors will do anything to eliminate some of the fear that might be contributing to doctors prescribing unnecessary procedures?
What is interesting about the claims of defensive medicine is that the more wasteful tests the medical professionals do, the more likely it is that the choice not to do those tests becomes malpractice.
The standard for determining whether a physician committed malpractice is generally something along the lines of whether they acted the same as a reasonable, similarly situated, trained, careful practitioner would act in the same cirmumstances. If they did, and a bad result happens anyway, its not malpractice. If they did something a professsional like that wouldn't do, or didn't do something they would, they expose themselves to malpractice claims.
So if the medical community as a whole starts testing everyone who has the sniffles for rabies, and it becomes something a reasonable, trained, physician would do, you can bet that the doctor that doesn't do it and their patient contracts rabies is going to get sued.
The reality is that the experts themselves create the standards by which they need to practice and avoid malpractice.