Technology and Health Care: The Bleeding Edge
I remember an incident a view years back that really made me despair about our collective ability to get a handle on health care costs. I was consulting to a large, multi-site radiology practice that was taking a look at its MRI practice. While there were a small set of MRI scans that made up the bulk of the work (e.g. knee, hip, spine, etc.), each radiologist had small differences in how they ordered those scans, i.e. which view of the joint they wanted in what order. These differences tended to reflect differences in training.
The site chiefs believed that it would be more efficient if the practice could agree on standardized approaches (known as “protocols”) to ordering these scans. This would be especially useful in cases where a study ordered by one radiologist (e.g. during an ER visit) was read by another in a different location. It would also be easier to develop standard templates for the radiologists to use in documenting their findings.
All the chiefs could see the benefits of this idea. We put together a committee—with several subcommittees—to develop the protocols. Several of the chiefs volunteered some of their younger colleagues, because they thought this would be a good leadership development opportunity. We worked hard over several weeks and developed a proposed set of protocols for review.
When the final set came before the chiefs for review, several became controversial. The draft protocols for knee, hip, and shoulder contained many more views of the joint than any of the chiefs—all very experienced—would generally order. Implementation of these protocols would have led to a significant increase in costs and a degradation in appointment access, since these studies would now have taken longer.
The protocols were “remanded,” so to speak, back to our committee. What became clear in the ensuing dialogue was that the younger physicians who had recently completed training were demanding more views. Our first reaction was to assume that this reflected a lack of confidence, leading to a need for more views. It turned out, though, that it really reflected changes in the underlying technology that made the additional views more likely—but still not very likely—to reveal positive findings of one form or another. Rather than deferring to the chiefs, the younger physicians stuck to their guns, convinced that settling for a smaller number of views was poor medicine.
We were at an impasse. I remember a later discussion among the chiefs. One of the chiefs, a very respected and experienced radiologist, ruefully admitted that he felt uncomfortable second-guessing his younger colleague about the knee protocol. “You should see her at work,” he said. “she can find things I never would have found.” While we did implement some of the protocols, we ultimately abandoned our effort to develop a consensus around the rest.
One of the iron rules of health care is that if the technology is available, it will be used. And, yes, that means we will sometimes find things that would not have been found before and that patients will benefit as a result. But it may well be the case that one might have to scan many, many patients with this new and more expensive technology in order to find a single case of the finding in question. The physician wrestles with a tension between his or her duty—enshrined in both law and professional ethics— to the patient in front of them and their responsibility—often less clearly defined—to be good stewards of the resources of the health care system. Patients, for our part, tend to complain about “waste, fraud and abuse” in the health care system when it is tied to the actions of others. When it comes to our own care, however, we tend to want the physician to do everything possible.
I don’t have a tidy set of ideas for reining in health care costs, mostly because I can easily imagine why most of them won’t work very well. I am fairly certain, though, that if we don’t find a way to use our ever expanding array of health care technology more judiciously, the health care system is going to collapse under its own weight.
“The physician wrestles with a tension between his or her duty—enshrined in both law and professional ethics— to the patient in front of them and their responsibility—often less clearly defined—to be good stewards of the resources of the health care system. Patients, for our part, tend to complain about “waste, fraud and abuse” in the health care system when it is tied to the actions of others. When it comes to our own care, however, we tend to want the physician to do everything possible.”
Some nuances have to be interjected here Peter. The first is that physicians are under herculean pressure from their hospitals to send any patient who remotely qualifies for a cat scan, mri, sonogram. Secondly, although, i have been helped by a cat scan I vigorously object to be sent for more tests than I need. I experience this tension with my present physician which results in the doctor’s visit becoming a tug of war rather than the assuring or informative visit it is meant to be. Paradoxically a person’s age while qualifying for most expensive tests become a baromete for unnecssarily invasive procedures.
Obama has crticized the Hospitals who are the principal culprits. In fact the situation is worse for the doctors than it has ever been with hospitals making record profits while doctors fare poorly. The same treatment in the hospital compared to the doctor’s office cost thousands more. This is a gross injustice.
Hi Peter, the missing piece of protocols and guidelines is study of effectiveness. Sure, the younger radiologists pick up things that the older ones miss — but if it makes no difference to the outcome of the patient, much of what they are doing “extra” has very little intrinsic value. Recent studies, for instance, show that the use of stents as a prophylactic treatment (not during a heart attack) produces “pretty arteries” but might even make cardiac events more likely. Yet, interventional cardiologists seem undeterred from recommending cardiac stents at higher and higher rates.
This is all really hard for doctors to accept but they are going to lose control of the discussion, as well as the trust of their patients, if they don’t start demanding evidence of the effectiveness of the technologies they use.
P.S., this is a really good argument for the bundling of payment for diagnostic services — if one doctor thinks he needs three views and another needs two, that’s okay, — but there really is no “need” to pay the guy who needs three views extra. That’s the real issue with imaging technology: the demand that every view be separately reimbursed.
“… the health care system is going to collapse under its own weight.”
Hmph. Well, few enough people were concerned about oil adventurism, war profiteering, and the collapse of the federal budget. Pardon me if I spew some bitterness about it being a darned convenient time to whine about not having enough money now that a select number of golden parachutes have left the ship. Let’s just concede “health care” is not the issue and move on from there.
That said, I do thank you, Peter, for this post. Let me offer another small story from the other side of the health care system. My wife has suffered a few significant medical conditions over the past several years. She generally eschews those extra tests, doesn’t want to be a bother, and thinks her doctors are doing their best. But my perspective is that she hasn’t gotten significantly better in the last seven to nine years. Is there a place for us to request the young radiologist who can “find things (others) never would have found?” Can I snarl an epithet or two at my employer’s insurance company and insist they man-up to their responsibilities?
More apt for the issue at hand, why does the discussion continue to get framed in extremes? Is there something wrong with sending a person for basic tests that will cover 90-99% of the possibilities? Then if something isn’t uncovered and the patient is still suffering, let’s continue to listen to the person, and engage the more skilled “younger colleague” to find what other doctors find difficult? If it takes a single-payer insurance system to keep its nose out of the loop up to this point, then anything less is a sell-out. If the president and the Democrats can’t deliver some relief, I’d say they will be singularly undeserving of future support. At least from this discerning medical consumer.
I worked for a while for the anesthesiologists in a hospital surgery and while some may have ordered tests for patients that they had little belief would do more than protect them from being sued, most did so in a dtermined and relentless effort to give their patients the best chance of getting well. That’s the kind of doctor I want for myself and especially for those I love.
Crystal, there are two issues.
First, the notion that more is better is so wrongheaded. My mother in law became a complete invalid because of an ill-advised test that went horribly wrong.
Second, heretofore scorched earth medical practice has been accompanied by scorched earth medical reimbursement. The best thing that we can do is to simply draw a line in the sand about how things will be reimbursed, and compensate a doctor for making a diagnosis (broadly speaking), not how many diagnostic tests he orders. This will push arguments over necessity where they belong — between doctors in a group, or doctors and hospitals.
Thanks for all the thoughts. Some points of clarification:
In this story, I’m not talking about “wasteful” or “unnecessary” tests or interventions in the sense where there is widespread agreement that, for example, one should not give antibiotics for viruses. Here, we are already talking about people who are suffering enough pain that they need to be worked up and have a radiological study done. We are talking about the marginal value (and cost) of additional views. In some cases, the cost is justified, in some cases it may not be. But it’s very fuzzy and most physicians are going to err on the side of being cautious. That’s what I would probably want, too. Therein lies the challenge.
The 64-slice CT is another good example of a challenging technology. Because it can image coronary arteries, it is often seen as a substitute for invasive diagnostic procedures that carry more risk. But the 64 slice CT is not without risk itself (you get a reasonably high dose of radiation) and now that the technology is out there, it will start getting used for studies where the benefits are less clear cut. Lord only knows what will happen once 128 slice CTs are on the market…:-)
I wish I had more hope in comparative effectiveness research. The underlying assumption is that the results of good research will drive clinical practice. But the reality is that there are a lot of other influences on clinical practice that sometimes outweigh the research. The evidence for screening mammography in average risk women under the age of 50 is, to put it charitably, equivocal. That doesn’t stop millions of women aged 40-50 getting referred for screening mammography.
The idea of compensating doctors for episodes of care rather than on a fee-for-service basis isn’t completely new. Back in the 90s, we heard a lot of talk about physicians accepting various types of “capitation.” But physicians aren’t, by training, terribly good at managing risk and many physician practices lost a lot of money trying to do this.
Peter, physician ability to manage capitation depends on the type of capitation — and for many, whether it is limited to their own services. Many large physician groups in California are still capitated. But I am not talking about capitation (per patient). I am talking about service or diagnosis related bundled payments, which would be very different from capitation.
Hi, Peter,
One of the rules of thumb that holds true in business generally (and in the consumer marketplace) is that technology gets significantly less expensive over time. Thus a computer server that costs $20,000 today will probably cost $10,000 in a year or two. If you’ve ever sprung for for a flat-panel television and then looked at the prices for the same model six months later, you’ve experienced it :-)
Why doesn’t this pattern hold true with medical technology? (Or does it?). I’d think those MRI scans would be significantly less expensive in a year or two, just based on the degradation in technology prices. Is it a case of hospitals and other medical clients perpetually needing the cutting-edge best?
Because (a) they keep upgrading it and (b) so much of it is protected by patent and (c) they effectively charge whatever they want for it anyway.
Sure, in an unregulated free market, that’s the norm. Health care is not a normal unregulated free market.
Hi, Barbara, thanks, that is what I would have suspected. It leads me to ask: do you think that paying per-episode rather than per-test or per-treatment would effectively curb the rush to latest-and-greatest technology?
It might. But the thing you must remember that the latest and greatest technology might provide virtually no benefit over the more recent technology. More likely, however, it will simply slow down the incentive that doctors have to be the owners of this technology. This is actually a really subtle issue — Doctors have two reasons for wanting to own technology — obviously, to the extent they can profit from it, they get more money. Reducing the extent of that profit makes it a less attractive proposition. But just as if not more important is that the demon RBRVS that Medicare uses to reimburse physicians institutionally ascribes more value to tests and procedures than it does to the judgment and diagnostic skill of doctors. This is a case of getting what you pay for in its most perverse form. This simply has to be changed in order for cost containment to have any hope of taking hold (as well as if we want to increase the number of physicians going into primary care).
I’m wondering if having the coolest toys is a powerful marketing tool that specialists can use to attract referrals from primary care physicians.