Several years ago the prestigious Institute of Medicine, the health arm of the National Academy of Sciences, revealed something startling about U.S. health care. Many Americans get too much, at the same time others get too little. And those in both groups have a good chance of receiving care that could injure or even kill them. That framework for overuse, underuse and misuse caught on and has become the gold standard for how we should think about medical care.
Too little care is easy to understand, and so is care that might kill us, but too much care? How can that be? More is always better, right? That’s certainly what society tells us.
For starters, think direct-to-consumer drug ads, which tell us to ask our doctors about drugs for incontinence, low sex drive, nasal congestion, toenail fungus and any other disease or condition for which they have a cure to sell. A study by the Kaiser Family Foundation a few years back found that people do as the ads direct them to do — ask their doctors for the promoted drug. And yep, the docs give patients what they want.
Last week I was visiting with a New York City primary care doctor who told a tale that suggests that this business of crowning consumers kings and queens of the medical marketplace, rules who demand and get what they want has a very big downside.
A trim young man, age 29, who worked in the financial industry and exercised regularly, went to see the doctor. He said he was having dizzy spells and was worried about some neurological disease. The doctor spent nearly an hour with him, taking tests, doing a thorough examination, and concluded nothing was wrong that warranted the neurological the patient was demanding.
The very next day the man was scheduled for one of those super-duper executive physicals that come with the high-paying job he had. That physical also showed no abnormalities that required further examination. Yet the patient persuaded the second physician to give him a referral for an MRI. The MRI also showed nothing that would explain his dizziness.
Not satisfied, he called the first doctor again just to be sure there was nothing wrong with him and again discuss his symptoms. The doctor told me this patient must have racked up over $5,000 in costs to the health care system all paid for directly by his employer or by his generous employer-provided insurance. Much of it was wasted dollars.
Why does this matter to the doctor? After all, he’ll get paid for dispensing his clinical judgment. But in the brave new world of health care consumerism, patients have also found a voice. They fill out those patient satisfaction surveys, and they write reviews on Internet sites like Yelp.
“If I get bad reviews on Yelp or low satisfaction scores, I get fewer patients, or the insurance company reduces what they pay me,” the doctor said, adding that doctors often simply give in to patients’ demands even if their clinical judgment tells them otherwise.
That’s hardly good medical practice, but it seems to be what the marketplace requires. The result puts doctors on a collision course with the Institute of Medicine’s push to make physicians practice good medicine and heed the consequences of overtreatment.
The New York doctor brought up another point — fairness — and that relates to underuse of care. The U.S. health care system is hardly fair, and inequality is growing despite Obamacare’s subsidies that help people buy insurance coverage. It may be growing because of Obamacare, which bakes in a trend that already was starting: higher deductibles, coinsurance and copays, which shift more of the cost of medical services to patients themselves.
The doctor worried about that, too. Sky-high deductibles — as much as $13,000 for a family — might deter someone without a lot of money from getting a needed MRI.
What can patients do? Sometimes it’s not easy to know whether you need a particular test or treatment. A good place to get help with your decision is the Choosing Wisely website (www.choosingwisely.org) sponsored by the ABIM Foundation, which furthers medical professionalism. The foundation works with medical specialty societies, the AARP and other groups, and has created lists and other tools based on scientific evidence that will help you judge whether you need some commonly promoted tests and procedures.
It’s one tool to help you get enough health care but not too much.
Editor's note: The Rural Health News Service is funded by a grant from The Commonwealth Fund and distributed through the Nebraska Press Association Foundation, the Colorado Press Association, the South Dakota Newspaper Association and the Hoosier (IN) State Press Association.