Some ways to cut medical costs

The Thinker by Rodin

Are we paying too much for medical treatment? Ask a physician and they would probably tell you that you are not paying enough. Ask the rest of us and we would say, “Hell yeah!” One clue that physicians may be myopic on this is to compare how much Americans pay for health care vs. other countries. In general, Americans pay much more money for inferior outcomes.

It’s well known that a lot of the money we spend on health care is wasted on unnecessary procedures and treatments. Other spending is fraudulent. Medicare is a fee for service insurance program. All sorts of fraudulent and fly by night outfits bill Uncle Sam for bogus, superficial or overpriced treatments. These costs amount to billions, if not tens of billions a year. The problem is hardly limited to Medicare. The same is true in the private insurance market. I have a Blue Cross/Blue Shield standard option plan. My insurance company blithely went along with all sorts of medical treatment for me that turned out to be a waste of money. I had veins removed on my leg a couple of years back. Remove extra veins and the theory went the remaining veins would better take up the slack, relieving pressure on my foot and thus the numbness I was experiencing. My legs look great but the surgery had no effect on solving my problem. Indeed, it might have exacerbated it because I had to wear compression stockings for weeks after surgery. If you have a nerve impingement issue, this makes symptoms worse.

All sorts of parts of our medical system are ineffectual. We depend on physicians, but it is clear that many of them are ethically compromised. No doubt you have witnessed what I have seen many times in doctors’ offices. It’s amazing physicians can get any work done with all the drug representatives coming in and out of their office. Like Santa Claus they come loaded with Christmas presents, often including catered lunches for the doctors, but also plenty of drug samples for their pricey proprietary drugs. (I know this because I get reports from my wife, who works in a neurology practice and sees this happening regularly.) More than one physician I have encountered are on a first name basis with these drug company salesmen and women. This is not surprising since they see a whole lot more of the physician than I do.

A little legislation is in order. My physician suggested a statin for my high cholesterol. He wrote a prescription for Lipitor, which came with a $75 copay for me and costs Blue Cross hundreds of dollars for each bottle. He has done this for other drugs he has prescribed for me, even though I have repeatedly told him I prefer to start with a generic drug, and use a branded drug only if necessary. I am currently trying to get my Lipitor prescription changed to a generic. It may be that I need Lipitor, but I doubt it. I seem to have garden-variety cholesterol issues. I suspect that he prescribed Lipitor by default because of the Lipitor brochures in the examining rooms and likely on his desk. (I sometimes wonder if he is on the take, and gets a percent of any prescription he makes.) It rarely occurs to my physician to give me a generic drug. I’ll bet that your physician is the same way.

Only one physician I associate with has the presence of mind to start with a generic drug (my cardiologist). As a result my heart medicines cost about ten dollars a month instead of hundreds. No one seems empowered to tell physicians what they can and cannot prescribe. It is clear that many are in the pocket of drug companies. There needs to be a law: physicians must treat with a generic drug if available and escalate to a branded drug only for a compelling and urgent need, to be enforced by local medical boards. Moreover, the AMA should change their code of medical ethics. It should be unethical for physicians to meet with drug company representatives unless it is at neutral forums where counterpoint is possible. It should be unlawful to accept any of the bountiful gifts they receive from these drug companies either.

If we cannot enact common sense laws like these, then physicians offices should at least have a prominent policy statement in their lobbies saying how they interact with drug and similar medical companies, so patients like me can know in advance and maybe shop elsewhere. They should record and annually publish statistics on the companies that came to call, who they saw and what freebies they received from these companies. As consumers, we have a right to know if our physicians are being influenced. Right now we have to trust that the physician is looking out for our best interest.

Our primary care physicians must remain our speed dial, but it is clear to me that the primary care system is breaking down. PCPs are generalists by training. As medical knowledge has increased, it is clear that they can no longer sort it all out. What we need now are centers of expertise that can assist PCPs. A PCP would still be the one we would go to for physicals, urgent cares, cold, flus and the like. When an issue reaches a certain degree of complexity, the physician would elevate it to a center of expertise. I can use myself as an example. Both my vein surgery and tarsal tunnel surgeries were clearly a waste of time and money because they did not solve my problem. However, if it had been presented to a team of specialists (who should not be on the payroll of any health insurer), they might have had me follow a more logical course. They might have researched foot numbness like I had, figured out the tests I need, diagnosed sciatica as a likely condition and treated for that first, starting with physical therapy, then chiropractic therapy. My PCP suspected neuropathies and sent me to a neurologist. What I needed were teams of experts: a neurologist, a podiatrist, an orthopedist and likely others to put their heads together and present a step by step treatment plan, probably moving from most likely to least likely, based on my symptoms. My problem was beyond what my PCP could handle, beyond writing me referrals. Besides he had boatloads of other patients he also had to juggle.

The Affordable Care Act is moving toward elements of what I have in mind, which proposes outcome-based reimbursements rather than for a fee for service model. It all starts with a proper and intelligent assessment. The patient is the ultimate person that should approve final payment. Did the treatment solve his problem? Did the treatment persist?

A new payment model might look something like this. Unless the problem is simple enough that a PCP can handle it, the first payment would be to an outcome center for a treatment plan. It would be based on as complete a medical record as exists for the patient. The second would increase payment to 75% when the treatment plan is completed, with perhaps staggered payments if the treatment plan will require months or years. The outcome center would reimburse specialists as needed. The balance would be paid three months later when the patient certifies that the outcome was satisfactory. This would give everyone incentive to get the treatment right the first time. Moreover, physicians would begin to align themselves to meet the market for what are medical needs actually are.

There is no socialized medicine here. Those who want to see a specialist on their own would still have complete freedom to do so. The government would not dictate treatment plans or what are reasonable patient outcomes, although existing institutions like the National Institutes of Health can shepherd the creation and certification of outcome centers and best practices. Patients would get better, faster and more effective treatments. Physicians could take pride that they are doing what is best for their patient as part of a holistic approach. PCPs would find their jobs more manageable. Moreover, health care resources would align toward the efficient needs of consumers. Of course change is always scary, but changes like these are long overdue.

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