Friday, February 26, 2010

When is Consumer Health Care Choice Rational and When Does it Become Irrational?

When taking an intercontinental flight a person has many choices – which airline, where and at what time to leave. When boarding the plane she can choose to deplane at any time before the doors are closed. She can choose among many options that are offered by the cabin staff. When technical issues arise however, i.e. when flying through a storm, the pilot is expected to choose the correct option for safely completing the flight. Why in this situation is it the pilot and not the passenger who makes the choice? This is because the complexities involved are quite sophisticated, requiring years of training and experience.

The situation is similar in health care; the patient has many choices in many situations. The patient can choose a physician, primary care or specialist, who appears knowledgeable and caring and has a personality in tune with that of the patient. Patients can choose to be compliant and learn as much as possible about their medical situation. The patient can always choose to refuse any or all treatments. The reality is when accepting treatment for a complex situation like the airline passenger flying through a storm, the expert, in this case the physician, is in the best position to chart the course.

One of the major problems in today’s medicine is that frequently even in very technical situations the patient/family is given the responsibility to determine the appropriate action. Sometimes patients are given options which they are not trained to understand and sometimes the choices contain options that are inappropriate in light of the patient’s overall condition. In other instances patients/families wish to receive treatments that are also inappropriate because of the patient’s medical condition. These too should not be offered. The problem is an unrealistic sense of patient autonomy which is among the major reasons why our health care is so outrageously expensive. To deal with this problem and avoid irrational care I have suggested a team of other professionals to assist the physician and patient to choose among beneficial treatment/s.

During the current health care debate many noted experts have suggested several reasonable reforms. They have mainly focused on changes in the payment system and some have suggested reforming medical malpractice laws; however, missing from the present discussion is the much needed change in the way we practice medicine. Until we as a society are willing to create a mechanism to clarify the role of patient choice and physician responsibility, successful health care reform will elude us.

Thursday, February 18, 2010

United States (U.S.) Health Care Costs versus The United Kingdom (U.K.): What We Can Do About It

The Organization for Economic Cooperation and Development (OECD) is the body that generates comparative national data regarding health care spending. This involves the compilation of massive amounts of data, thus the comparisons are about three years behind the present date. The latest data I could find is for the year 2007. In that year the U.S. devoted 16% of gross domestic product (GDP) to health care while the U.K. devoted 8.4%. In equivalent dollars per person spending was $7290 in the U.S. and $2992 in the U.K., quite a difference. Disease adjusted mortality was then and is now superior in the U.K. than in the U.S. If I had compared the U.S. to another industrialized nation, the exact figures would be different, but the lesson is the same: the U.S. spends much more than any other nation on health care without having superior results.

These differences have been the focus of many investigations and publications. Noted experts Uwe E. Reinhardt, Gerald F. Anderson and at that time Ph.D. candidate Peter Hussey published a paper in Health Affairs 2004 examining differences in cost from an economic prospective. They focused on a number of factors, some of which cannot be changed (1-2) and others that could be addressed (3-5).

1) As nations’ GDP increases, the fraction of spending on health care also increases.
2) Because of the many opportunities in our large economy we have an increased cost of recruiting and keeping talented people in medicine.
3) In our present system there is greater market power in the supply side versus the demand side for health care. This is because we have a greatly fragmented payment system.
4) Because of the greater complexity of our medical system we have significantly greater administrative costs. These two factors, 3 & 4 could be addressed by creating a series of standardized insurance plans across the country (see link to policy paper on right hand margin- look under health care bank).
5) We have a practice of medicine that lacks discipline when weighing benefit to risk ratios, leading to much non-beneficial care along with the excessive use of technology. To address this need for a cultural change in the way we practice medicine I have suggested a timely physician and nurse support system and a dialogue between patient and physician as to what constitutes beneficial care (see policy paper (link in navigation bar on the right hand side, appropriate care committees and a new style of hospital admission form).

Additionally, superiority in physical diagnostic skills helps explain why physicians in the U.K. rely less on expensive diagnostic testing than their colleagues in the U.S. American medical students now have to demonstrate physician diagnostic skills before graduation. This is certainly progress in the right direction, but is it enough? I think not. Presently there is not an oral exam focusing on physical diagnosis after three years of an Internal Medicine residency; hence this expertise has disappeared. Dr. Abraham Verghese, Professor of the Theory and Practice of Medicine at Stanford University, comparing the physical diagnosis training of medical students in the U.S. versus that in the U.K., stated in The American Medical Association Journal of Ethics, 2009:
I have no doubt that if we attempted to put in place a standardized test using standardized and real patients, with examiners watching for technique as well as understanding of the methods of bedside examination, our students and residents would (much as they do in Canada and Britain) spend a lot more time mastering these skills…..I have great confidence in the clinical knowledge and patient management skills of our students and residents, but the area of bedside skills is in need of improvement, particularly if we are to practice cost-effective medicine and minimize a patient’s exposure to radiation. Imaging tests are valuable and often necessary, but if simple bedside skills make them unnecessary, then lack of such skills is not just costly, but dangerous.

I completely agree with Dr. Verghese. I along with most of my colleagues are concerned that presently most our Internal Medicine residents are not skilled in excellent physical diagnostic techniques. Certainly challenging these residents to learn superior physical diagnostic skills will not completely solve our problem of an exorbitantly expensive style of medicine; however, it would be a step forward for making our medical system less technologically dependent, more rational, safer and less expensive.