Doing with Less Medical Care
The American Board of Internal Medicine Foundation (not the American Board of Internal Medicine itself) in conjunction with Consumer Reports did a study recently that indicated that many, if not most, of the medical tests are over used and not necessary. While not really a surprise, it clashes, to an extent, with the federal government's push to mandate that insurance companies and/or taxpayers cover a number of preventative illness tests. And it clashes with health care institutions' urging and patients' insistence on taking certain tests and medicines.
Cited by the study were mammography imaging, colonoscopic exams, PSA blood work, head CAT scans, EKGs, MRIs, stress tests, uses of antibiotics, drugs for acid reflux, even scanning for cancer in patients who have had cancer. The study did not say never use these tools, it said they should be used appropriately. The idea is to curb the overuse and therefore help reduce the cost of the health care system.
Ironically, the biggest complaint against insurance companies from patients, doctors and now the government, is that they won't cover the costs of some tests and procedures. Who are they to get between me and my doctor? All they want to do is protect their profits. True, perhaps, but is it any different than the government that now pays for a lot of health care being interested in containing costs? At the same time, they are seeking to make certain these costs are covered by someone else. A bit contradictory.
Interestingly, I have on my desk a letter from a medical screening company urging me pay $119 to be screened for stroke, vascular disease and osteoporosis. These are usually done at a local church and I have had them done even though my own doctors screened for some diseases and two of my children who are doctors say that the tests are generally unnecessary. The screening company in the meanwhile claims that problems were caught in one out of 14 people. That's out of 62,000 screened. That also means that it cost over $7 million to find those problems. This is a cash, not insurance, proposition. Is it worth it? Apparently 62,000 people thought so and this isn't the only company doing such cash screening.
Perhaps they feel that the $119 (sometimes there's a discount) is reasonable compared to those really big testing bills one gets from a hospital or clinic.
Obviously, there is a problem. And, study after study shows we do too much testing and take too many drugs, particularly antibiotics. According to some doctors, patient pressure is a big factor. According to all doctors I have talked to, liability is a big, big factor. Don't test and the doctor risks being sued if he (or she) misses something. Yeah, the liability insurance company offers coverage, but the hassle, time, concern for reputation, and the possibility of not being able to be insured in the future argues for being safe. Keeps everyone happy except it costs a lot.
Other countries with centralized (government) care don't have those problems. It also isn't very easy to get screening tests done there. Because tests are discouraged and tightly controlled, resources to do the tests are limited resulting in long waits. That's why some Canadians go to the U.S. for certain procedures. Cadillac (or Lexus, or Mercedes, or Porche) systems are nice to be in as long as we have budgets to match. And, it appears we don't.
Everyone is afraid of rationing. The death panel suggestion about end-of-life care reflects that. Mainly, we worry whether WE can get the tests WE need and want, and preferably have a third party pay for them. Plainly, however, we've got to shrink the care system. I've contended that moving back to a cash system or paying for your own individually tailored policy, or buying policies that cover catastrophic (whatever your catastrophic levels are) situations, would help contain costs. Encouraging (not commanding) people to buy policies at an early age in anticipation of medical catastrophe would be helpful. There would still have to be a safety net for such things as chronic disease, but catastrophic coverage would help if minor or normal procedures are out-of-pocket.
However, failing that kind of an approach we're left with our hybrid - third party insurer/employer/government, individual, but regulated, or government coverage. Or, we can move directly to a government paid, single payer, system that risks not only high taxpayer costs and bureaucratic entanglements, but a virtual rationing through cost controls.
Whichever direction we move, we have to face the real problem of medical practitioners' liability when restricting tests as recommended in the recent study. Although establishing "accepted practices" for medical procedures based upon studies and expert panel conclusions appear reasonable, human beings are not mechanical robots. They are chemical cesspools whose individuality is as much a reality as "accepted practices" which tend to change with knowledge of which we have only a little bit. There has to be room for "this is the correct way, but…".
In the meanwhile, testing is not the only issue. Delivery or accessibility and cost of the system as well as personal health practices are, perhaps, even larger cost issues. I recall the movement 40 years ago (or more) to move away from longer hospitalization stays for everything from child birth to heart attacks. We now have 36 hour hospital care for birthing and a couple of days for heart attack or less than a week of hospitalization for heart surgeries. The lesson is that we can probably do with a lot less than we do.