In the April 25th Archives of Internal Medicine Dr. Steven Schroeder, now UC San Francisco affiliated, but a former medical director of GWU’s outpatient clinics and HMO (my medical school alma mater), presents a comprehensive analysis of the rising costs of health care over the past few decades. While his perspective is not available online to nonsubscribers, I thought it worthwhile to highlight a few of the many salient points he presents.

Those of you who have read my previous rants know that I’ve placed heavy emphasis on the need for a change in physician practice patterns to impact on the escalation of health care costs. I proposed that physicians be provided with feedback as to where they stood relative to their colleagues to promote voluntary assessment of choices made, and surmised this would result in a reduction in wasteful ordering of tests. Well, it appears this has already been tried with some success. Dr. Schroeder noted a wide variation in practice patterns when at GWU, varying by as much as 17-fold among physicians in annual laboratory costs. When clinicians were notified of this, solely for informational purposes, a second, behind-the-scenes audit revealed a 29% reduction in costs of laboratory use. Interestingly, reductions were similar for those physicians in the highest-cost and lowest-cost thirds, while those in the middle were unchanged. Dr. Schroeder argues, rightly, that medical cost containment is not synonymous with rationing needed care.

I’ve argued in the past that care will inevitably be rationed as the patient ranks burgeon and patient age and infirmity rise; it will either be done rationally and purposefully, or desperately and reactively when the system is on life support. Clearly, the component of overspending cited above falls into the “waste” category and should not be confused with rationing. Much of the other health care spending that I predict will be curtailed in the coming years will be subject, I suspect, to greater philosophical and moral debate.

Dr. Schroeder’s dissertation covers a wide range of issues, among them hospital and specialist utilization and costs, and some of these will be addressed in subsequent posts.


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