Factors Affecting the Cost of Health Care – An Internists Perspective

Brian R. Riveland, MD
July 2009

“There are three types of people in this world: those who make things happen, those who watch things happen and those who wonder what happened”

Mary Kay Ash

The cost of health care in the US is a daily news item. It is the major focus of the Obama administration. Recently “providers” got together and promised to cut health care costs; however, missing in this extensive coverage is a step-by-step outline of just how are we going to do this?

Let me get this straight right from the beginning. I have no idea how to fix the problem. However, I do have opinions as to where, as a practicing internist, I see that health care dollars are wasted. This certainly is not an all inclusive list and each item could be an article in itself.

  1. Improper incentives. Nothing new here, but it is very clear the system rewards procedures, testing, short office visits, and subspecialty utilization. The examples are endless and here are but a few. I can spend 5 minutes discussing the pros and cons of PSA testing with my patient, or indicate he needs to have a PSA test done and order the test in 5 seconds. This during the same office visit I should be discussing living will, medical power of attorney, lifestyle changes to manage his hypertension, diabetes and heart disease, weight loss efforts, smoking cessation, immunizations, preventative health measures in addition to doing a full history and physical exam and addressing all of his concerns that he has learned on the TV through direct-to-patient marketing by the pharmaceutical companies. I will not get paid any more for doing any of the counseling or advising once a certain level of visit is obtained. I also do not believe that negative incentive models are the answer either (i.e. capitation); however, the system does not recognize cognitive services for our patients. As in a previous article, I also believe the current and worsening supply of primary care physicians will do nothing but make this worse.
  2. Defensive Medicine. While there is a great deal of difference of opinion as to how this contributes to the cost of medicine or even how to define it, it is like the saying about pornography, I know it when I see it. I see this everywhere with every specialty, it is universal. Evidence based medicine (see below) can be used to guide our thought process and decision making but this is often not an adequate defense in the courtroom. The examples here are endless and the reality is the threat or fear of being sued is predominant.
  3. Patient Expectations. Patient expectations drive testing and procedures. More testing is viewed as being more thorough and better care by many. I hear this every day from my patients in one way or another. When a patient walks through the door with a notion of what needs to be done and that is not fulfilled, this drives the behavior of the practitioner. Marketing is done to the public to have screening tests that have no evidence behind it (CT scans, Carotid Ultrasounds, etc) – I spend a great deal of time trying to educate the patients why this is not indicated.
  4. Lack of enough evidence based medicine and the inability to disperse this information in an efficient way. I am a true believer of evidence based medicine. However in an internal medicine practice where a typical patient has multiple medical problems, 8-10 medications, social and financial issues, overlying depression and a reimbursement system that does not incentivize evidence based medicine I am truly struggling to apply this to the majority of my practice. I believe there is tremendous room for improvement in getting this information out to practices in a meaningful way.
  5. Pharmaceutical Industry. Once again the incentives for the pharmaceutical industry are contrary to the need to manage costs. Financially it is more productive for XYZ pharmaceuticals to produce a new ED drug and market that heavily to the public, or developing another ACE inhibitor or Beta blocker and market that heavily to the physicians, rather than develop drugs for more difficult, yet rarer, conditions that have an impact for disease management and improvement. While we are on the drug issue, yes I listen to the pharmaceutical representatives; I like to get samples to try for my patients, but why is there not a system for sampling generics? Many times I wish to try a patient on a medication before prescribing. If I had access to all generics in my sample cabinet I would think that would incentivize the usage of effective generic medication tremendously. The pharmaceutical industry is now latched onto the direct-to-patient rebates for patients to effectively negate the disincentive the insurance industry is giving the patients by making the higher-cost medicines higher. I love it. I believe there are many other issues with the pharmaceutical industry that I am likely not qualified to comment on.
  6. Insurance Industry. Do the millions of dollars going to the CEO’s and to Wall Street make our health care system more efficient? Perhaps I should leave my comments at that.
  7. End of Life care/futile care. The costs of the last year of life are overwhelming. This has many contributing factors however a key component of this is our social and cultural approach to dying. In many other cultures death is embraced as a natural part of life, a transition not to be feared. Our cultural outlook is that death is to be avoided at all costs, and our technology is allowing us to avoid death even if that means on a ventilator and with a feeding tube. Overlying this is the defensive medicine aspect of care referenced above. For those that are interested there is an excellent book called “The Troubled Dream of Life, living with mortality” by Daniel Callahan. Again as physicians we are de-incentivized to spend time discussing these issues with our patients.

I am sure there are many other obvious medical waste issues you all see on a day to day basis. I would welcome your comments on this and perhaps we can keep a running list of what we see as the waste in the health care system. I believe our policy makers would be enlightened to hear this from those of us working in the trenches.

Until Next Month,

Brian R. Riveland, MD