The doctors—we are possibly the thorniest of the problems to solve. I believe any honest physician would admit that there is overutilization. Most, if not all, would either lay the blame on other medical professionals’ shoulders, or argue that they are forced into this practice pattern by patient expectations and medical-legal pressures. While this is accurate as far as it goes, the bigger truth is that practice patterns, under these pressures, insidiously morph until they become the “norm.” There are striking regional differences in treatment costs. A somewhat lengthy, but cogent and eye-opening discussion of this I referenced in the “problem” section, but it is worth revisiting.  An analysis of one of the most expensive health-care markets in the country, McAllen, Texas can be found here and here. It should be required reading for anyone interested in health care. A briefer illustration of the problem, taken from a different angle, can be seen here with the “prostate cancer test.” And with variations in practice patterns come differences in outcomes, as reported in USA Today. When you add in the small but disproportionately costly percentage of providers, physician and non-physician alike, that are dishonest, the drain on our resources is magnified.

Obviously, the crooks need to be targeted and removed from the system. But how do we deal with the larger problem of competent, well-meaning physicians who have become accustomed to doing everything, at least once, when the same result could have been obtained by doing less? First, it falls on the schools and residency programs to start shaping thoughtful, cost-effective practice patterns early. This is no small feat in an academic center where getting experience is prioritized, by definition meaning more tests and procedures. Out in the real world, some have suggested paying for outcomes rather than visits or procedures. This sounds great, but judging outcomes in a sick patient population is a tough job and adjusting for this even tougher; if you don’t do it right you penalize the doctors willing to treat the hardest cases, and this would result in brain-drain and medical care access problems down the road. As it is, doctors don’t earn a penny more for coming in at 3 a.m. than they do at 3 p.m., and often emergency care is delivered free of charge (self-pay is usually no-pay in the medical field), so shifting to bundled pricing based on outcomes is not without hazard if we want to maintain a robust and committed physician pool.

Guidelines for good medical care exist in many areas and should continue to be developed and disseminated; adherence to them has been shown to result in better outcomes. However, they remain guidelines and not mandates for a good reason: clinical studies deal with groups of patients. Without the ability to deviate from guidelines to adapt to the needs of the individual patient without the long arm of the legal system coming down on our heads will result in substandard, “cookie-cutter” care that benefits no one. Along these lines, numerous studies are underway to assess the value and appropriateness of new testing and treatment options, known as cost-effectiveness research. This has come under fire by some as a ploy to limit access to health care. While I suppose the results of such research could so be misused, I think not establishing rational guidelines to new, expensive techniques will lead to even greater abuse. Here is an example of the combination of guidelines and flat fees that appears to be  a win-win situation.

It has been suggested that health-care delivery systems such as the Cleveland Clinic and the Mayo Clinic are the answer. These are highly integrated organizations with salaried physicians capable of providing high quality, cost-effective care for much less than other institutions. Porting this model to the general medical community, however, poses a daunting challenge. It should also be noted that internationally renowned institutions like the Cleveland Clinic have access to patients who can pay full retail to offset discounted fees, and to generous philanthropic donations. A more approachable example cited is Bassett Healthcare, which also has a salaried structure. So, are salaries the answer? I’ll address this in part four.


NEXT: The Solutions, Part 4, The Doctors, continued


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