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Monday, August 24, 2009

How to waste over $21,000 before lunch

Health care in the United States is too expensive, and because it is too expensive, a large number of Americans do not have access to it. The story that is not being told in the national debate about health care reform is what exactly costs too much, and how to remedy the situation. Unnecessary costs directly related to the practice of medicine are only a portion of the waste, but the magnitude of this kind of expenditure may be huge. Saving a fraction of this money could make it possible to give health care to everyone who needs it, withhitout any negative impact on our national budget.

The schedule below is a reasonable scenario of what happens in many primary care offices. The costs are inexact, but within range. The major causes for this waste are pretty easy to remediate: 1. primary care doctors don’t spend enough time with patients because they are underpaid for counseling. 2. Providers and patients don’t know what things cost. 3. Doctors are afraid of being sued for malpractice. 4. Our culture in medicine discourages considering costs in decisions about care.

This is my morning, as a primary care doctor in rural Idaho. It is not a real morning, but it could have been.

8AM—arrive at the hospital, perform two treadmill tests with nuclear imaging, ordered by physicians for patients at low risk, because of concern about malpractice should they have a heart attack. Each costs $3000, one unnecessary, the other of which could have been done without nuclear imaging at my office for $200.

9AM—see two patients at the hospital. One remains in the hospital because she can no longer live at home and can't afford to go to any of the extended care facilities that have openings, at a cost of $1000 for the day. The other is there because she wasn’t insured and waited too long to see a doctor for her migraine headache, costing $2500 for her MRI scan of the head and $1200 for her day’s stay at the hospital, and $600 emergency room fees.

9:45—get to the office late because the uninsured patient was news to me, so I didn’t plan on seeing her. See my first patient who has a physical scheduled. She wants “a complete lab workup” even though all of her labs were normal last year and nothing has changed, because her insurance will cover it. She has been having back pain. Since I don’t have time to talk to her about the natural history of back pain I order an MRI scan and physical therapy. Labs: $120, MRI$2500, 8 physical therapy appointments $1000.

10:30—next patient has numbness in his fingers when he is anxious. He can’t afford counseling and I don’t have time to discuss relaxation techniques with him so I refer him to a neurologist. He will see the neurologist 3 times, at a cost of $150 per visit, and she will order a head MRI scan for $2500.

10: 45—next patient has a cough and a stuffy nose for 4 days. I think it is viral, but she is sure she needs antibiotics. I don’t have time to explain the side effects and futility of antibiotics so I prescribe an antibiotic. She says the generic doesn’t work. Cost is $120 for that and $200 for an inhaler which is what I think will work, though if she just waited she wouldn’t need that. Because she smokes and I am worried about being sued, I order a chest ex-ray. That is another $200.

11:00—patient comes in for followup on his diabetes. He has been in poor control, but since I don’t have time to counsel him on diet and exercise in a way that will probably have an impact, I prescribe a new medication. He is already on generic pills, so I have to prescribe insulin, and because time is an issue, I use the newest insulin delivery system which is easier to explain. This costs $150 and doesn’t make him any happier, plus his risk for complications is just as high because he will continue to gain weight.

11:15—the next patient comes in for followup of an abdominal CAT I ordered because I didn’t have enough time to counsel the patient on how to avoid constipation. The CAT discovered a cyst on his kidney and a nodule on his adrenal gland. He is beside himself with worry, even though both of these things are usually normal findings. I reassure him that I will get a followup CAT scan to make sure they are normal, which will use a better technique and cost $2000 (but I don’t tell him this because I don’t know what it will cost and have no idea what his insurance will pay.) Because he is so worried I don’t have time to see my next patient who has to leave, and go to the emergency department with her pneumonia at a cost of $1500.

So… before lunch over $21,000 has been wasted. And this may significantly underestimate potential for cost savings because most primary care providers in the US see more patients than this, often one every 10 or 15 minutes, and have even higher rates of testing and referrals than I mention.

It is likely that, with malpractice reform, increase in payment for counseling in primary care, a knowledge of and willingness to discuss costs, and the universal access to health care that would then be affordable, nearly all of this $21,000 + could be saved.


j. said...


Jean Gazis said...

The numbers here are what gets billed, which is not what actually gets paid, let alone what things really cost. Of course, that does not undermine the point being made. And the cost of processing all the paperwork is in addition.

Louise said...

this sounds very much like my day. I do have a little more time since my role is slightly different as an NP, but the pressure to build a practice to offset the expense of hiring me means more patients in less time, it becomes a vicious cycle.
I also see rampant waste due to unrealistic expectations of what medicine can and should provide through our current govt funded aid programs. I see patients who "threaten" to seek (expensive) care through the ED just because they can if I don't presribe whatever it is they want that particular day ... be it an antibiotic for a viral illness or a CT scan for a common headache or an MRI for back pain. I feel frustrated by the paper shuffling I do for Rx benefit programs which change willy nilly on a monthly basis without cause except that a different deal was made with a pharmaceutical company. LC

Janice said...

Yeah, and the numbers are inexact, because I get the info from patients in most cases. When I go to the billing office of the hospital to ask what things cost and how much insurance and patients actually pay, they either won't or can't tell me. I think that the numbers I quote are actually low, in terms of what is billed.