Less Is Often More

In the blame game of who is responsible for our broken healthcare system, society often sees the government and insurance companies as the institutions responsible for creating fragmentation and driving up health care costs.  While they certainly are part of the equation, we can also point the finger at a number of parties. Hospitals, the pharmaceutical industry and an unhealthy society take part of the responsibility but one often over looked contributor to increasing health care expenditures are physicians.

In The Cost Conundrum, Atul Gawande explores why McAllen, Texas is one of the most expensive healthcare markets in the country. In 2006, Medicare spent $15,000 per enrollee in this city which is nearly twice the national average. Gawande investigated several possible reasons why McAllen might have higher expenditures (better outcomes or a sicker population) but found that the primary cause of their extreme costs were across-the-board overuse of medicine. Gawande writes,

Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

This should not be surprising. With every medical procedure performed, the patient assumes a risk of complications. Medications come with the possibility of adverse affects, hospital stays brings an increased likelihood of hospital-acquired bacterial infections and imaging tests expose the patient to radiation. Furthermore, some hundred thousand people die each year from surgery complications, more than car crash fatalities.

The Archives of Internal Medicine published a study that aimed to develop a list of the top five activities in which physicians in internal medicine, pediatrics and family medicine could improve the health of their patients, in addition to reducing health care costs. Here are the recommendations they made:

Top Internal Medicine and Family Medicine (combined for overlap)

  • Lower Back Pain: Don’t do imaging for lower back pain within the first 6 weeks unless red flags are present.
  • Screening: Don’t obtain blood chemistry panels (eg, basic metabolic panel) or urinalyses for screening in healthy adults who don’t have symptoms.
  • EKGs: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
  • Cholesterol Lowering Drugs: Use only generic statins when initiating lipid-lowering drug therapy.
  • Bone Density: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.
  • Sinusitis: Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis (inflammation of the sinuses) unless symptoms – which must include purulent (full of pus) nasal secretions AND maxillary (upper jaw bone) pain or facial or dental tenderness to percussion – last for 7 days OR symptoms worsen after initial clinical improvement.
  • Pap smears: Don’t perform Pap tests on patients younger than 21 years or in women have had a hysterectomy for benign disease.

Top 5 Pediatrics

  • Throat Infections: Don’t prescribe antibiotics for pharyngitis (sore throat) unless the patient tests positive for streptococcus (Strep throat).
  • Head Injuries: Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.
  • Fluid in the Middle Ear: Don’t refer otitis media with effusion early in the course of the problem.
  • Cold Medications: Advise patients not to use cough and cold medications.
  • Asthma: Use inhaled corticosteroids (a steroid medication) to control asthma appropriately.

Most physicians practice with their patient’s best interest in mind. But the rules, regulations, and payment mechanisms in the current medical field influences the way a physician thinks, whether consciously or subconsciously. A physician may order extra tests not because evidence calls for it but to calm the fear of a medical malpractice lawsuit. Or a procedure may be ordered, although not needed, because it brings in revenue. With these recommendations in mind, physicians should note that less is often more.