“Well, if we can do without you for two weeks, then maybe we do not really need you.”
That was the response of a former boss to my request for a two-week vacation years ago.
This is horrible employee management, but there is some general wisdom here.
If you can go two weeks – or a month or a year – without something, did you really need it anyway?
COVID-19 has raised this sort of consideration within the health care system.
Most hospitals shut down all non-emergent procedures in order to focus on the pandemic. In some cases, patients refused to go to the hospital or physician offices for fear of getting the novel coronavirus.
In many cases, patients have done just fine with putting off elective procedures and diagnostic tests. This has caused many to inquire about the need for excess medical testing and procedures.
A much-read 2017 survey of 2,106 physicians revealed that roughly 20% of medical care might be unnecessary. This included 22% of medications, 25% of tests and 11% of procedures.
In April, JAMA published a very detailed study estimating that the U.S. wastes $101 billion annually on unnecessary health care tests and procedures.
This study took a very conservative approach to defining overuse and was based on Medicare data and not commercial insurance. Previous studies (such as Healthcare Finance) set the cost at up to $200 billion every year.
A 2015 article in The American Journal of Managed Care argued that up to one third of our health care spending could be unnecessary.
If these studies are accurate, it would account for rising health care costs and wait times. The sticker price is shocking and forces us to ask why this is happening.
Here are four common reasons why providers over-treat patients.
Clinics do not always receive detailed information from prior providers about a patient’s medical history. Lab work and radiological imaging are not always sent in a timely fashion.
Then there is the medical information that comes from the patient. Many patients are poor historians. In the absence of an existing patient-physician relationship, everything needs to be verified.
This is coupled with the fact that communication between different medical specialists is frequently poor. The cardiologist does not always know what the oncologist is planning, for example.
All of this can increase cost. As electronic health records are being networked across health care systems, we are seeing improvements, but there is still a lot to do.
We live in a litigious culture. It seems like anyone can be sued for anything, and health care workers are not immune.
Physicians cite the fear of malpractice suits as the number one reason for unnecessary health care testing and procedures.
In order to protect themselves, primary care providers go the extra mile or two in order to ensure they did not miss anything, or at least to look like they were overly diligent.
This drives up costs not only due to extra tests and procedures, which are more about risk management than patient care, but also due to the medical liability policies physicians must acquire.
3. Consumer-driven trends
Patients shop for health care providers like they are picking a restaurant. Lobby and waiting room aesthetics, staff friendliness and services provided are all important considerations that attract patients.
Unfortunately, the idea that the customer is always right has impacted health care like the rest of the service industry.
It is common to see patients insist upon testing, procedures or even surgery when the physician is advising a wait-and-see approach. In such cases, physicians and surgeons can feel obligated to provide unnecessary services.
Maintaining hospitals, clinics and medical practices is expensive, with a great deal of overhead costs ultimately passed along to patients.
Unused X-ray and MRI machines can cripple a practice. Laboratory equipment needs to generate revenue, or the office will close.
While unfortunate, economic pressures can impact decisions about the level of care.
Further study is needed, but 70% of physicians believe an unnecessary test or procedure is likely to be performed if it profits the provider.
We did not discover that Americans were being over-tested and over-treated because of the pandemic.
This has been known for over a decade. For example, a 2011 JAMA survey revealed that 42% of U.S. primary care physicians believe their patients receive too much care.
We have simply been apathetic about addressing this trend.
The epidemic of over-treatment has caused soaring health care costs and placed excess strain on the system. Many hospitals and clinics have become dependent upon revenue from excess testing and procedures, which creates long wait times for patients.
Therefore, what do we do?
First, we need better data and research to know what is really going on.
The vast majority of physician and health systems want what is best for their patients, so accurate information will shape how medicine is practiced.
Research showed a decade ago that hospitals and clinics were overusing antibiotics, which increased costs and caused patients to be more susceptible to multi-drug resistant pathogens.
The industry acted, and we have made great strides in antimicrobial stewardship.
When studies revealed that we might be overusing cardiac stents, interventional cardiologists updated how they practice.
Second, patients need to be more patient.
Every time we are sick or hurt, we want something done immediately. We want our doctor to snap her fingers and make us better.
It is time we stop insisting upon services and start listening to our physicians. Patients are part of the problem when they demand doctors and nurses do something when wait and see is the proper approach.
It is time we start taking this issue seriously before health care costs can no longer be contained.