Financial Incentives in Medicine

A recent article in the New York Times “Many Doctors, Many Tests, No Rhyme or Reason” reminded me of the distorted financial incentives that permeate the practice of medicine in the United States. In the article, the author, a NY cardiologist states, “In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.” He then goes on to detail the evidence of excess both at a national level and on an anecdotal basis.

Unfortunately, I have to concur with his bottom line conclusion: “Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.”

This article reminded me of my own early experiences in the hospital. I remember as a third year medical student I commented to one of my classmates that my internal medicine hospital rotation was so easy! All we did was call consults every morning based on all the abnormalities we found on the labs and imaging from the day before. Okay – so I’m being a bit glib and over-exaggerating. But I do remember the conversation and sentiment very distinctly. I felt like we spent a lot of time asking for consults when maybe they weren’t necessary. But then again – I was a naïve third year medical student with no experience. What did I know? 

But I have to say, I’ve had those same nagging feelings through the years  – that utilization of consults and testing is driven by financial incentives; maybe even “throwing a bone” to one of your medical colleagues. Where I did my internship, many of the medicine patients I took care of on the wards were either uninsured, underinsured or within an HMO model. In that situation, where there really wasn’t the willing patient (or matching reimbursement) I felt we were a bit judicious and restrained in our testing and consults. But in other environments where I have practiced, where patients were more generously insured, I definitely have felt a trend towards overutilization and unnecessary testing. 

So what is a patient supposed to do in an environment of distorted incentives for testing and work-up? Some solutions will hopefully come from our site, MyDailyApple. Over the next several weeks, we will be introducing a set of content, features and tools on MyDailyApple to assist patients with understanding the world of medicine and to take action with managing their health.  Some of this is already there and I encourage you to check it out.

 
But even with all the great Health 2.0 technology, it is probably unrealistic to expect a patient to look up information and search on the internet while in the hospital. So how can an individual advocate and maybe to a certain extent – protect themselves within this environment? Probably one of the first steps, in addition to all of the technology out there, is an old-fashioned Health 0.0 solution - engage your provider in an honest discussion. Someone has to start the process. And it is always fair to ask, “Do I really need this? What happens if we find something – then what? What if there is a false positive result? What are the alternatives? Is this all necessary?” Physicians probably aren’t used to such pointed questions. But times are changing – and so should the nature of the interaction between physicians and patients. And perhaps this will start the frank dialogue to understand the distorted incentives that operate in the American health care system. 

I think one of the final quotes from a hospital executive in the New York Times article really sums up my feelings on this one.  “The hospital is a great place to be when you are sick. But I don’t want my mother in here five minutes longer than she needs to be.”