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.”
