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Monday, September 20, 2010

what do I mean by cost effective medicine?

It is not uncommon for comments about cost effective medicine to be met with mistrust by patients.  Saving money is fine, but not if it means that when I, personally, as a patient, am in pain or sick, will have to wait for relief, get suboptimal care or be denied a life saving treatment. I, as a doctor, am also a patient, and can fully sympathize with this opinion.

When I envision cost effective medicine, I mainly see an absence of cost ineffective medical interventions.  Without these big yellow lemons of common medical practice, there will be more time and money to provide care that is meaningful. So what are the top shelf worst and most cost ineffective practices? It would be beautiful to see a well funded study of this question, but I haven't seen such a thing, so I will dip down into my well of 25 years of medical experience and pick out several of the things that I, as a patient, don't want to happen to me. These are things that are costly, common and have very little value in terms of maximizing health or happiness.

1. I go into the emergency room with severe abdominal pain and before anyone asks me questions that might be relevant (have I ever had this before, what did I just eat, have I ever been evaluated for this and how...) an abdominal and pelvic CAT scan are ordered and I receive a radiation dose equivalent to over 300 chest x-rays and a bill for $2500.

2. I reach a ripe old age, am having significant problems with my memory, joints, digestion, plumbing and whatnot, and suddenly my heart stops while I'm sitting at a meal at the nursing home.  I am resuscitated, rushed to the hospital where I remain on life support for a couple of weeks with lines and tubes and beeping machines as my family tries to figure out whether I really would have wanted all of this. Costs for this kind of end of life care often run as much as $10,000 a day.

3. I go the the doctor for high blood pressure, and sure enough I do have high blood pressure.  He goes into the sample closet, gets me the newest anti hypertensive medication on the shelf, shown by drug company sponsored studies to have minimal side effects, and I take it, then fill the prescription which costs about $300 a month when a generic of proven track record would have worked just fine and cost $4.

4. I have chest pain and tell my doctor.  She wants to make sure she isn't sued if I have a heart attack, even though my chest pain is only with taking a deep breath and is never associated with exercise, so she orders a nuclear imaging stress test.  The radiation dose is huge and the bill is $6000. Later I get lung cancer, and cannot be at all sure that it wasn't caused by radiation.

5. I have knee pain and am overweight.  I can't get dietary counseling because my insurance doesn't cover it, but I can get an x-ray, then some arthroscopic surgery which doesn't help but costs about $30,000. I now am overweight, have knee pain and a nifty scar on my knee.

6. I am uninsured or underinsured so can't really afford to go to a primary care doctor for my cough.  It gets worse, so I go to an emergency room.  The evaluation includes a chest x-ray, breathing treatments and an expensive antibiotic and no followup or smoking cessation advice.  I didn't need the antibiotic and get antibiotic associated diarrhea and eventually require hospitalization. Total cost of this perfect storm is in the 10s of thousands of dollars.

7. I am an 80 years old man and go to my doctor  for a physical exam.  He says that I need a prostate exam and PSA testing for prostate cancer. He finds prostate cancer, I get evaluation then radiation therapy, causing me to decline to the point that I now need to be in a nursing home because of urinary and fecal incontinence. I would not have died of the prostate cancer had it gone undiagnosed.

8. I am a 40 year old woman, go in for a physical and am told to get a mammogram. The mammogram is abnormal so I get another 6 months later. It is still abnormal so I get a biopsy.  The biopsy is normal. When I get my next mammogram it is abnormal too because I have a scar.  I get an MRI of my breasts and that is equivocal.  I get another biopsy which is normal.  This process is repeated yearly until what is left of my breasts resembles the surface of the moon.

There are cost effective solutions to all of these problems which rely on adequate access to primary care physicians and good choices about when to use technology. Making medicine cost effective is about making it better. Dollars spent on health care should be in the service of health and happiness and nothing else.


Anonymous said...

As noted elsewhere, medical care is not synonymous with health care. What works best is to provide health services and good nutrition to pregnant people, then follow up care, then good health education and occasional minimally invasive exams through adulthood and then later life medical care appropriate the the individual's condition. These are, as a matter of public fact, better dispensed not-for-profit by a national health service than for profit by insurance and pharmaceutical firms.

Janice Boughton said...

Best dispensed, I think, by any system that pays providers to make their patients healthy rather than per encounter. Fee for service lacks incentives to make the patient well enough that she does not need care. If doctors were paid to provide health care for a particular population, the incentives would be to make patients healthy and independent. National health services set this up through a large centralized system, which can work, but can be cumbersome and inefficient. Community funded health care or capitation of some sort would also provide appropriate incentives.