The cost of medical care gets a lot of attention from
politicians and policy pundits (including both the influential and people like
me); we are often told that Medicare is going to bankrupt the nation, that
people are getting unnecessary, expensive, and potentially harmful services
(except, of course, when those services are being received by the speaker or
writer or those they care about). We are also told that quality and cost
control can go hand-in-hand. While sometimes they can, they do not always. As I
have noted in the past, prevention does not always save money in the long term.
(I guess if we wanted to save money on health care, we’d encourage people to
smoke, eat fatty food, and not exercise, so they could have their heart attacks
young – and of course not treat them – so they’d never get old enough to be the
multi-morbidity high cost patients!)
Two recent “Perspectives” in the New England Journal of Medicine address this from different angles.
“Cents and sensitivity:
teaching physicians to think about costs” (July 12, 2012), by Rosenbaum and
Lamas, looks at the education of physicians (students and residents) in terms
of how they are taught what medical tests cost, and conclude that it is very
little. They open with a typical rendition of a student presenting a new
patient to residents and attending (faculty physician). As the student
painfully proceeds with identifying less-and-less probable diagnoses for the
person who almost certainly has pneumonia, this list of expensive tests to be
done to “rule out” the improbable grows. “Our
profession has traditionally rewarded the broadest differential diagnosis and a
patient care approach that uses resources as though they were unlimited.” The
issue is not that we should only consider one diagnosis; it is that expensive
tests to look for the most unlikely diagnoses need not be done immediately, but
only when a patient is not responding to therapy for the most likely (including
after testing to “rule in” or “rule out” common, not rare, competing
diagnoses). We certainly do not need to do every possible test that can be done
to make a diagnosis even after the first, best, test confirms the clinical
suspicion; this is the basis of an educational model that the authors cite by
another scholar, Chris Moriates.

But the most important contribution that they make is to,
matter-of-factly, state that not having insurance is a negative quality
indicator, that there is “even [my
bold] variation on such fundamental measures as having health insurance or a
connection to a regular source of care.” The attached map shows the
regional and sub-regional variations in health insurance; white areas have the
lowest level of uninsurance (5-14%, Massachusetts lowest), and black areas (on
the Texas-Mexico border) the highest, >50%.
The article by Rosenbaum and Lamas cites the views of a
number of medical ethicists, including several who believe that it is an
abrogation of the Hippocratic oath to limit the care provided to the individual
patient in front of you based on cost. I do not agree; while the primary
criterion should be a consideration of the cost-benefit ratio (how much will
this help the patient per dollar of cost), it is also true that there are
certain interventions for certain conditions that are too costly to provide for
everyone who needs it equally. And that is the crux of the issue. While one can
(if a bit disingenuously) say “I cannot worry about ‘society’, I have to care
for the patient in front of me,” the fact is that the patient in front of you
for whom you may be considering an expensive intervention is not randomly
selected. At least in the US, it is probably someone with health insurance that
will pay much of the cost. It is certainly someone who has made it through the
medical maze to get your attention. If the person in front of you can afford to
pay for any service, whether they need it or not, but there are others who
cannot pay for even the services they most definitely require, this is not
coincidence nor is it irrelevant.
Perhaps the primary responsibility for cost-control should
not be at the individual doctor-patient level, but at the societal level, such
as is done in Great Britain through the National
Institute for Health and Clinical Excellence (NICE) that evaluates
interventions and decides, based on cost-benefit ratios, whether the National
Health Service will pay for them. However, as individuals’ out-of-pocket
expenses for employees’ contribution to insurance premiums, deductibles, and
co-pays continue to increase, more and more people are finding that, insured or
not, cost is an issue. Remember that “low cost” is relative; most “low cost”
interventions are still a lot of money, easily moving into 4, 5, or 6 digits,
for folks to pay out of their pockets. Rosenbaum and Lamas end their article
with “Protecting our patients from
financial ruin is fundamental to doing no harm.”
We may have different perspectives on where the limits are
in providing costly care to an individual, but making sure that everyone,
wherever they live, has access to quality care is critical. And ensuring that
it is not financial or insurance status that limits access is the first step.