Monday, July 5, 2010

These Are the Things That Drive Up Costs And Cause Them to Vary

It has always been a mystery to me why the high costs of care are such a mystery.

The answers are right in front of our nose. They are called medical culture, societal culture, human nature, and human uncertainty. These are things no amount of data and no number of algorithms can correct.

Take use of imaging.
It grows at 15% to 17% each year. In “The Uncritical Use of High-Tech Medical Imaging,” NEJM, July 1, 2010, radiologist B. J. Hillman and futurist J.C. Goldsmith dissect out these human factors.

1. Patients’ desire for more imaging, as advised by friends, the Web, the lay press, and direct-to-consumer advertising.

2. Compelling financial interests of physicians, who sometimes benefit from more imaging.

3. Physicians’ concern over liability risk, both by physicians who order the tests and those who interpret them.

4. Style and content of clinical education, which spills over into medical practice, and which encourages “shotgun,” “no stone unturned" diagnostic approaches,

These factors are cultural in nature. The authors conclude we will have to change the culture of medical practice as the imaging industry confronts fee reductions and utilization controls.

Consider cost variations.
These have been usually attributed to provider greed, excessive specialization, technological overuse, underuse of appropriate care, variations in clinical training, but rarely to poverty, dysfunctional socioeconomic condition, and delays in treatment until diseases become prohibitively expensive to treat. Even more rarely do we confront these “scary truth; the science behind medicine is sorely lacking, and often there is no clearly right answer" (A.M. Epstein, “Geographic Variation in Medical Spending,” NEJM, July 1, 201

Ponder patient expectations - to be relieved of pain - and the physician mission – to relieve pain
. Go no further than hip and knee replacements. These procedures relieve pain, big time, and the public and physicians know it. Here is how the July 2 NYT explains it, “There is nothing like a new hip or knee to put the spring back in your step. Patients receiving joint implants often are able to resume many of the physical activities they love, even those as vigorous as tennis and hiking."

No wonder joint replacement is growing in popularity. No wonder in 2007 U.S. surgeons performed 806,000 hip and knee implants (the joints most commonly replaced), double the number performed a decade earlier and approaching or exceeding one million this year. To doctors and patients there can never be too much of a good thing, a thing that returns patients to full function and partaking of the good life.

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