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Monday, May 16, 2011

My TED Talk

The Technology, Education and Design group was founded in 1984 in Monterey, California, to promote ideas that primarily related to information systems. Since that time, the focus has expanded and now includes subjects of global relevance as expressed in their mission statement: ..."We believe passionately in the power of ideas to change attitudes, lives and ultimately, the world. So we're building here a clearinghouse that offers free knowledge and inspiration from the world's most inspired thinkers, and also a community of curious souls to engage with ideas and each other."

TED talks have been criticized as being elitist and as reducing scientists and scholars to circus performers, but having watched several of them, I think that the discipline of having to express ones most important ideas in 18 minutes in a format that can be understood by just about everyone is a great idea. As far as elitist, I suppose that probably applies, since it is unlikely that anyone who is not well spoken and at least moderately well known will have the opportunity to speak. I, for instance, will not be invited. Which is why I will write my TED talk up on my blog rather than waiting for a phone call from whoever it is who telephones those who are worthy. There are TEDMED talks as well, which are about my field, but all of those folks are in some way hugely famous having won prizes, written books or earned honorary degrees. They talk about fascinating subjects, but so far I don't see anybody writing about whyamericanhealthcareissoexpensive.

A TED talk is kind of like a super-slow motion elevator speech. It involves both the idea to be explained and a mini-biography of the person with the idea, as a way of giving the idea a human setting. In that way, a TED talk is different from a church sermon and different from a college lecture.  Here goes:

Half my life ago I became interested in practicing medicine. I came from a relatively well educated family, but not a medical one. My mother had painfully limited her choices by never finishing college. For me, medicine offered the opportunity to nurture while being financially and in many other ways independent, after paying the reasonable price of several years of indentured servitude. Besides the requirement for independence, my family had given me a powerful message of the value of frugality. As I moved further into my training in medicine I was frequently troubled by what looked like waste. I was trained at the Johns Hopkins School of Medicine, one of the most well respected medical schools in the world, so I withheld judgement about what seemed to be excessive use of testing and medications. I entered practice over 20 years ago, and saw a more haphazard use of technology, and experienced the system of cooperative managed care as practiced in my first job as a general internist at Group Health in Everett, Washington. There, certain expensive resources were jealously guarded, but other ones were used even when inappropriate. When I moved away to a private practice setting, I learned how efficient I could be by getting to know my patients well and discussing options with them for evaluation and treatment. As the years went on, there were even decision trees to help decide on the best alternatives, though those did not always represent my patients' needs.

Frugality was offended, however, when my patients were referred to specialists or ended up in the emergency department due to sudden changes in their health.  In these places tests were ordered without a second thought and medications prescribed without conversations about costs or alternatives. One day after a CT scan ordered by another physician showed a confusing but not very concerning finding on a patient who had far too many medical tests due to her inability to express herself well, the radiologist and I, while speaking on the phone together, simultaneously said "I could lower healthcare costs 30% tomorrow." We had simultaneously become so frustrated with the way medicine was practiced that it was no longer a discussion about this particular patient, but of the whole way tests, procedures and medications were ordered.

Not long after that, in the heat of debates about what to do with an American health care system that fails to offer even marginal care to millions of low and middle income citizens, I began to do rough math to determine exactly how much money was being wasted on unhelpful, unnecessary and potentially harmful testing and treatment on a regular basis.  By practicing medicine as a primary care physician often does, it is more than possible to waste 10s of thousands of dollars a day, without even considering the overuse of more expensive procedures such as surgeries and prescription of medical contraptions of dubious utility that goes on outside of my areas of expertise. 

This overuse of unnecessary medical interventions is primarily due to the long standing fee for service system in much of medical practice, in which a physician is paid not for keeping a person healthy, but often just the opposite, seeing them or doing things to them. Humans in general want to be healthy, happy and live a long time, then be allowed to die in peace and comfort. So much of medicine is not in any way furthering those aims. In addition to fee for service, third party payment (insurance policies paying for medical care) protects physicians from free market forces, since patients don't have any direct interest in the cost of their medical care and insurance companies can and do simply pass on outlandish costs to insurance consumers as premiums.  A CT scan, for instance, costs much more in the US than in other countries and is used much more frequently, at a cost of 10s of thousands of lives every year from radiation exposure and with no proven benefit in many cases.

The fear of being sued for malpractice is more than a small influence on these issues, though lack of incentive to reduce costs is much more important.  Certainly physicians are sued if a cancer is discovered at an advanced stage when a well timed CT scan or other procedure could have saved a life, however much of the drive to sue for malpractice is based on becoming impoverished by medical costs and due to dissatisfaction with physicians, all of which can be traced to an inefficient and non-patient centered approach to medical care.

The third party system is also a fierce temptation to commit fraud.  Complex billing schemes make a patient's bill nearly impossible to interpret, and so it is rare for a patient to question a bill in any way that is effective.  An insurance company paying the bill may have an incentive to  make sure billing is honest, but the insurance company employee investigating a bill has no actual knowledge of what service was performed and a very difficult time tracing whether such a service was appropriate.  I'm not sure whether there is a theorem that states that where fraud is possible it is occurring at the rate that is just slightly below the system's ability to detect it, but there should be. Huge amounts of money are inevitably being outright wasted due to fraudulent billing.

So what is the simple solution to all of this?

Physicians could simply start thinking of cost as an issue when prescribing testing, procedures, medications or medical devices. This should not be the only consideration, but in a world in which resources are limited, it is absolutely necessary that cost be part of the discussion. These discussions should be between the physicians and their patients, taking into account all of the issues.  Patients also need to begin to take some responsibility for health care costs, participating in shared decision making in a well considered way. 

The third party fee for service system of payment for medical care must go.  Without direct connection of costs to good outcomes, those costs will continue to rise without any appropriate value.  A physician who is paid a set amount to keep a patient healthy will have much more incentive to practice cost-effective care than one with a blank check and no other motivation to do well than his or her own ethical belief system.  A system that combines the successes of staff model health care cooperatives with the personal touch and intimate contract of concierge medicine can provide those incentives at a fraction of the cost of providing the inadequate care we have now.  Eliminating fee for service medicine will help push physicians to use all of the networking technology available to communicate with patients in a way that is most convenient and effective for both parties.

The system of civil suits for malpractice needs to be significantly changed. Presently malpractice suits take years to be resolved, end up with angry patients and angry physicians, ruin lives and careers and often provide no compensation for an injured party. Suits contribute to physician burnout and attrition, which further worsens access to primary care. A good system would compensate patients quickly for injury and target hospitals and responsible physicians for improvement of knowledge, attitudes and systems to prevent further injury. No fault systems have been effective elsewhere, and mediation has already had a big impact on compensation for medical injury in the US. Quick compensation outside of the court systems should be the rule, not the exception in the US.

It has been a great pleasure to be able to practice medicine for nearly 25 years. I have been privileged to share the stories of countless people, to share their lives, meet their families, and to interact with physicians and nurses who combine compassion with humor and ungrudging hard work.  There is much that is caring and good about the practice of medicine as it is now. The nearly 20% of our gross domestic product that goes into the provision of medical care, even when wasted on tests, procedures, drugs and contraptions that are not helpful, is still contributing to our economy instead of that of China.  There is much to be grateful for. However there is also much that can be done to better focus all of this effort and money so that the millions of people who are suffering due to the inadequacies of our system are better served.





4 comments:

HMS said...

One wonders why medicine does not consider personal economics, and obviously the cost of medicine in particular, to be a fundamentally determinant biological health factor, to be taught right alongside organic chemistry. Every other creature in the natural world considers it as such.

Anonymous said...

Health care is too expensive because doctors are afraid to say "no." We have patients who stay on our hem/onc unit for weeks or months because they know how to play the system. "Severe abdominal pain" or mysterious chest pains occur every time the d/c papers appear. Ridiculous. Our hospital is free housing, food, cable, and meds for a LOT of people~!

Ohana Street said...

"Direct connection of cost to good outcomes" >>> I wonder if a study has been done/published re: this.

Great TEDTalk, btw ;-)

Ohana Street said...

Thought I'd share this though you probably had seen it already (via NEJM.org): "Primary Care Update -- Light At the End of the Tunnel??" http://www.nejm.org/doi/full/10.1056/NEJMp1205537?query=TOC&