A great deal of discussion followed the publication of the NY Times’ June 13 article “The $2.7 trillion medical bill” (including my own blog piece The high cost of US health care: it's not the colonoscopies, it's the profit, July 28, 2013). The article began with the cost of colonoscopies and went on to address many of the sources of the high cost of US health care. A more recent piece in the New England Journal of Medicine, “The thousand-dollar Pap smear” by Cheryl Bettigole seems like it could be a follow up. In some ways it is, but it also raises a number of other points that should be addressed.
Dr. Bettigole begins by describing a call from one of her patients, who complained she had been charged over $600 for her Pap smear, shocking both of them. She goes on to describe the tremendous role that Pap smears have had in (at least in developed countries) in almost eliminating the scourge of advanced cancer of the cervix; indeed, this test remains the best example we have of an effective screening test for any cancer. It is – or should – also be very cost-effective, as especially shown by studies that assume a $20-$30 cost for the test. So how did it get to be so expensive? Is it really? Is it necessary? A portion of the increased cost comes from the use of a more effective (and more expensive) method of preserving and analyzing the specimen (“liquid based”), but most of it comes from including a bunch of other tests. These include tests for human papilloma virus (HPV), recommended only for some women and at intervals less than routine Paps, and tests for sexually-transmitted infections (STIs) which may or may not be indicated based on the patient’s history and symptoms but are quite different from cervical cancer screening. Why? Because the laboratory, which makes money on this, often “bundles” these into an easy-to-order “panel” of tests (rarely accompanied by the price!), and busy clinicians check them off.
The insidiousness of this kind of effort to order more tests than planned (and, often, to find an unanticipated – and frequently unimportant – abnormality that requires more tests to follow up) is common, not solely for Pap smears but for many other lab tests, and contributes to the increased cost of health care for society, insurers, and individual people. Dr. Bettigole’s other point, however, is the role of the provider in contributing to this unnecessary cost by not ordering tests more carefully, and with attention to cost. She writes “`When I was in training, our attendings would ask a standard quiz question: “What is the biggest driver of health care costs in the hospital?’ Answer: the physician's pen. A mouse or a keyboard, rather than a pen, now drives the spending, but we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.”
It is a good point, and we should all be careful to order tests (and treatments) cost-effectively and teach our students the same. But this is not the sole answer; we need systems that encourage this sort of test ordering, and make it more difficult to do things that are not cost effective. It is parallel to encouraging our patients (and ourselves) to adopt healthful behaviors – a good idea, but not the answer for improving the health of a society so heavily geared to encouraging poor behaviors (drinking and smoking and guns and overeating and eating empty calories, etc. etc.). The idea that the "problem" is individuals' bad behaviors appears in lots of places in society, and frequently in medicine. This is not only victim blaming but an impractical approach to problem solving. In industry, a strategy called “six-sigma” has been widely adopted; its goal is to make bad outcomes resulting from individual error occur with a frequency approaching zero. The model is airplane flight, and trying to eliminate crashes, and it works because systems are put into place that make things work rather than saying to each pilot “Be careful! Remember to push the joystick in the right direction!”
At a recent Family Medicine conference, the excellent film "Escape Fire" was shown. It addresses many issues of problems with the health care system, including delivery systems, an emphasis on high-tech “rescue” care rather than prevention, and profit seeking by insurers, providers, and drug and device makers. A part of it also features Safeway's program for employee wellness. For some reason, the leaders of the ensuing discussion chose that as the first question: "does your employer encourage wellness?"
After a while I observed that this was not the main point of the film, and that mostly it talked about the need for system change. A student indicated he agreed with most of what I said but that there should be some "individual accountability". I should have asked specifically what he meant, but did observe that they have the ultimate accountability -- they get sick and die sooner. Of course, we should encourage our patients to eat right and exercise and not smoke and drive carefully, and we should ourselves. However, like trying to get all airplane pilots to push the stick the right way, getting each individual to always do the right thing is not the way to go. Few of us never drive too fast! Yet over the last 30 years there has been a tremendous decrease in traffic-related deaths, all of it from safer roads and more safely designed cars and 0% of it from people driving more carefully.
In occupational medicine behavior change is considered a weak third option after architecture and engineering. If there is a big window next to the factory floor where it is sometimes slippery, that is an architectural flaw; it shouldn't be there. But, if it is, you can put a heavy mesh screen over it so if people do slip, they don't go through -- engineering. Telling everyone to always be careful is good advice, but not a very effective solution. And yet, in our practices, with patients, with doctors, with social problems, we (as a culture) do it all the time.
Of course, an additional consideration in solely emphasizing individual behavior change is that we are wont to do it mostly with people whose “bad” behaviors are different from our own, and people who seem to be different from ourselves. We may overeat and need to go on a diet, but they are massively obese and at fault. We may drink sometimes, maybe too much, but they are alcoholics, or drug addicts. We could do a little more exercise, but they don’t care at all for exercise and its health benefits. We sometimes indulge in a piece of cake or a donut or two, but they only eat crap. We are sometimes in a hurry and not as careful as we should be, but they are maniacs on the road.
And, of course, they often look different from us, of a different race or culture. And really often they are poorer than we are (especially when we are physicians), and confronting, on a daily basis, a lot of challenges we don’t. Do they live in a “food desert” where the nearest grocery is too far to walk and they haven’t access to a car? Or it is unsafe to walk, for food or for exercise? Have they got a job or any chance of getting a job? Or are they “lucky” enough to have 3 jobs, and no time to “work out”? Judging others is a popular pastime, but it is not only often done without adequate understanding, it is rarely useful. We can and should encourage healthful behaviors and try to identify obstacles and help people overcome them, but we must focus primarily on the systems changes that make health possible in a more efficient and effective way than expecting everyone to change their behavior.
We can. The airlines have done it. The car industry (dragged kicking and screaming) has done it. The health care system can as well.
I am indebted to many wise comments made by many family medicine chairs on the ADFM listserve. The opinions and conclusions, however, are entirely my own.
So true in many respects...it would take a book for me to explain why I agree..
What are the standards that MUST be followed, by statute? Do you know that answer? It's very simple; so simple it's a trick question.
Another completely brilliant post. Dr. Freeman, I hope to meet you one day so I can shake your hand and thank you for producing this blog.
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