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.
Radley and Schoen, from the Commonwealth Fund, write in the July 5, 2012 issue about “Geographic Variation in Access to Care — The Relationship with Quality”. This draws on data from the most recent Commonwealth Fund Scorecard “Rising to the Challenge”, published in March, 2012, and examines how health care quality varies dramatically depending upon which area you live in. This is largely regional, but there are also “sub-regional” differences. They discuss a number of the common areas in which quality can vary, including adults with a usual source of care (93% best, 59% worst), high-risk adults who visited a doctor for a checkup in the past 2 years (95, 67), adults over age 50 who received recommended preventive and screening care (59, 26), and adult patients with diabetes who received recommended diabetes care (69, 27). They note that “…when we look beyond state averages, there are staggeringly wide gaps in people's ability to gain access to care in different communities around the country. We also find a strong and persistent association between access and health care quality, including the receipt of preventive care. Simply put, where a person lives matters — it influences the ability to obtain health care, as well as the probable quality of care that will be received — though it should not matter in an equitable health care system.”
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.
An excellent post, Josh! I wholeheartedly agree that we need something like NICE here in the United States. However, first we'll need something like the NHS delivering care.
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