Tuesday, December 30, 2008

Costs, the physician culture - On Draining the Health Care Financial Swamp

The doctor went on. “I’m curious. You know I’m the most expensive doctor in the city. Why did you come to me?” “When it comes to my health, money is no object.”

Milton Berle

The problem with the chart as surrogate is that the map is not the territory. ..The financial costs of imprecise observations leading to unnecessary and risky tests are not known. In a health system in which the menus have no prices, we order filet mignon at every meal.

Abraham Verghassie, “Culture Shock – Patients as Icon, Icon as Patient,” New England Journal of Medicine, December 25, 2008

Draining the health care financial swamp begins in medical school and in teaching hospitals.

The Good News

The good news? Medical students and residents have good intentions. And they follow their altruistic instincts. They order every test and procedure that might benefit patients, diagnose and treat patients, and please their teachers. These fledging doctors tend to be compulsive, a big reason they qualify as doctors. They don’t want to leave any test undone, any procedure unperformed, or any question unanswered their attending might ask.

The Bad News

The bad news? These same young doctors have little reason to pay attention to costs. There are no rewards for cost consciousness or for economic prudence. Anyway, technologies these days are all powerful, capable of looking inside the body and joints and measuring every metabolic component or function. That’s why looking, listening, and examining the patient often comes last. A third party will pay. Consequently, there are no tables or charts on any hospital ward or in any clinic listing prices for tests and procedures.

The objective of all dedicated physicians is to thoroughly analyze all situations, anticipate all questions from rounding attendings, have answers to all those questions about tests and procedures to back up your answers, and to move swiftly to do whatever was left out. There is always something missing, and the hospital, after all, is the place for quick one-stop analysis.


However, doing all of this leaves little time for listening to patients, conducting a thorough physical exam, or dropping by periodically to check for the latest developments.

When you’re up to your ass in alligators, it is difficult to remember your initial objective was to drain the swamp –listen, diagnose, and treat the patient. Instead, you are unwittingly draining the health care financial swamp.

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