By Dr Cary Presant MD We all know that medical care is expensive. Newspapers, television commentators, analysts and insurance spokespersons constantly remind us of this, as well as every employer and politician.
Some recent articles have extended the discussion about whether America is spending too much on treatments that are not producing the right health benefits. An article by Dr. F. Fowler, Jr., from the Foundation for Informed Medical Decision Making at the University of Massachusetts and his colleagues (Journal of the American Medical Association, Volume 299, Page 2406, 2008) along with commentary by Dr. G. Anderson and Dr. K. Chalkidou from Johns Hopkins School of Public Health (Journal of the American Medical Association, Volume 299, Page 2444, 2008) have asked how much the government spends on medical care and the patient’s perception about the quality of their medical care.
In the study, Dr. Fowler and his co-authors asked 4,000 Medicare patients, 65% of whom responded, about the quality of their care and the utilization of care, and compared their responses with the amount that Medicare actually spent on their medical services. They compared the lowest regions which spent $5,200 per patient per year with the highest regions which spent $8,500 per year.
The results showed some expected and some unexpected findings. The patients in the lowest spending area had fewer visits with the physicians (3.4 per year) compared to the highest area (3.9 per year), and the patients in the highest spending region saw more physicians (2.8 per year) compared to the lowest spending region (2.4 per year). The greatest differences were in the area of cardiac care (of course older patients more commonly die from heart disease than from any other cause). Only 23% of patients in the lowest spending region saw a cardiologist and the patients had fewer tests (40.1%), compared to the highest spending region, where 37% of patients saw a cardiologist and 64% had received a cardiac test. Despite this, and despite a higher utilization of specialists (3% in the lowest area versus 8% in the highest), the rating of their care as excellent was 63% in the lowest spending area compared to only 55% in the highest spending area! And in addition, patients in the lowest spending area saw their doctor less frequently!
As discussed by Drs. Anderson and Chalkidou, the outcomes of life expectancy and infant mortality have related more to education among women and average per capita income rather than the amount of spending per patient per year. Above a threshold of $2,000 per patient per year (for all patients, not just Medicare patients) there are a few improvements in outcomes compared to increased expenditures. Higher spending does not lead to increased health outcomes even in academic medical centers. And further, once patients have received explanations of all the risks and benefits of newer, more expensive treatments, patients do not always agree to more aggressive and comprehensive therapy.
Also of interest, is a report in the July 2008 Consumer Reports discussing the range of patient charges for care in various areas of the country. The 10 most “aggressive” medical centers included hospitals in New York City and Los Angeles, as well as Philadelphia, among others. The most conservative medical centers included hospitals in Texas, Utah, Wisconsin, Missouri, and Colorado. The health outcomes did not change compared to the degree of expenditures.
So what should we learn from these facts? First, you should NOT automatically conclude that your doctors are spending too much on your medical care. Your doctor is your best protection against too little medical care, and should be your best advocate against too much medical care. Therefore, we follow the recommendations of our primary care doctors and our specialists more than relying on the internet for guidance in care.
Even though the government might feel it is spending too much in your region, only your own doctor can advise you if you personally need more, or less care. So finding that right doctor who will put your needs above those of the insurance company is crucial to making the right decisions.
In order make certain that you are receiving, just like Goldilocks, not too much, not too little, but just the right amount of health care, you should follow these recommendations. You should know all about your physician through your physician’s website, and by knowing your physician’s reputation in the community. Your specialists should have good recommendations not only from your primary care physician, but also according other patients, and community organizations (such as the American Cancer Society or American Heart Association). Each of your physicians should always have earned your complete confidence (or else you should get a second opinion). You should always know about your hospital, and investigate its reputation in the community, its frequency of infections, its success rate in surgeries, and this data is available through your insurance company and national comparative websites.
You should also have frank discussions with your physician. Write down questions before you accept any kind of treatment. Do I need it? What will the doctor do differently if I have this test versus if I don’t? Will this test help me to live longer, or be more comfortable? What else do I need that you have not already ordered, and why would I need it? What are the benefits and what are the risks?
You should always ask your physician to coordinate your care with other physicians but you can help in this regard! Keep copies of your records from every physician including the notes from every office visit, and the results of all of your tests and x-rays. It is little additional work for the physician’s staff to make a copy for you that can be life saving if you visit another physician who might not have access to those results.
Have conferences with your doctor to discuss your diagnoses, treatment plans, expected outcomes, and risks. Make certain that prevention and screening has been stressed in these conversations.
Medicare has found that many doctors who own their own hospitals, laboratories, or radiology centers tend to overuse their own test and treatments, compared to doctors who do not own their own facilities. So be sure to ask your doctor or the office administrator is the doctor owns any facilities to which you are being referred. If so, you can inquire what other facilities can be sued, and whether the tests or treatments are really required. Sometimes a second opinion can help you decide.
Lastly, always have advanced directives prepared with your physician’s office, patient advocacy office in your hospital or insurance company, or with an attorney. Knowing what you want to have done in the event of serious illness which might not get better, and which might prevent you from making your own decisions, can only help you to avoid getting excessive treatments that you really don’t want, or guarantee that you will get treatments that you want despite the cost-saving preferences of your physician or your insurance plan.
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