Most of the effort in health reform remains on the payment and access side. The elephant in the room is the treatment side. I believe that this will move to the front of the debate in the very near future.

This recent NY Times article from March 29, 2010 nicely lays out the problem.

As prior postings have suggested, there is little incentive on the part of patients, insurers, or doctors to not over-treat, over-diagnose, use more costly options in general, and in general fail to exercise the common sense and cost/benefit analysis that all of us exercise every day as consumers when it comes to our own dollars. While many may believe that carriers may benefit from saying no, in the aggregate they say yes more than not, and merely pass on the costs in the form of premium increases. And to the degree that carriers are regulated, they may have incentive to pass on costs, which may translate into higher profit when they are accustomed to and permitted to bring a certain percentage of revenue to the bottom line. The more cash that flows through a company, in general the greater the impact and capacity to profit.

A significant flaw in a system that does not have the consumer spending and watching their own money, as the apparent absence of and resistance to regulations that will determine and enforce what will be paid for, if not how much will be paid when it comes to health spending.

I remember years ago when I did hospital work, I crossed out some routine orders on a patient, which included multiple vitamins. The nature of this patient’s problem was such that she had no need for these pills, which were being charged at a rate of dollars for each unit dose. I was called by the hospital administrator and asked to explain myself. I politely told him that I decided what was appropriate for my patient based upon clinical needs, not a routine set of orders. He was most unhappy with me, as I was obviously depriving the hospital of a massive mark-up on this drug, and by questioning and exercising judgment, was seen as a threat to its bottom line.

As gatekeepers physicians have the ability to say no to the optional, the more costly or the clearly not indicated interventions for their patients. If we treated each patient as if the patient was paying out-of-pocket, we would take better care of them. But we also know that we may face unhappy patients, defections from our practice, pressure from colleagues, hospitals, vendors and perhaps a decreased income. Threat to income is especially significant when it comes to the procedures that we perform ourselves.

So we will trash, dismiss, or ignore studies, guidelines and mandates that may bring common sense and cost-containment to medical care. The increases in premiums will keep on coming and the US health bill will remain a 6th of our economy rather than the more modest 9th or so of many other developed countries. To not go along to get along is a bit like tilting at windmills.

By the way, some will cite liability concerns as rationale for many of the excesses, especially diagnostic procedures. While this may be true in part, I believe it is a flip remark that at best is a small part of the problem. Physicians exercise discretion regularly, and accepted standards of care will support a well-reasoned decision to not do something just as it may require that something be done. That is the nature of malpractice litigation – physicians having to defend themselves for their decisions. Having reviewed many an NPDB report, the majority of lawsuits have to do with a bad outcome from something other than failure to perform a particular test.