The Virtue of Unnecessary Care

I case you didn\’t hear the news: the American Healthcare system is in financial crisis. One of the biggest culprits indicted in this crises is \”unnecessary care,\” with estimates ranging from $500-$650 Billion (total spending estimate is $2.6 Trillion) going toward things labelled \”unnecessary.\”  Personally, I think this is an underestimate, as it doesn\’t take into account the some big-ticket items:

  • Brand name drugs given when generics would do
  • Antibiotics given for viral infections (and the additional cost due to reactions and resistance)
  • Unproven costly care considered \”standard of care\” (PSA testing, robotic surgery, coronary stents)
  • The unnecessarily high price of drugs.

One of the main reasons I am an advocate of EMR is to measure and analyze care, eliminating that which is wasteful, futile, or even harmful.  The biggest burden on our system is not the fact that we have a hyper-complex payment system that hides the true cost of care.  The biggest burden is the wasteful care that this system agrees to pay for.  In fact, I suspect that the main reason our system has become hyper-complex and covert in its spending is to hide this waste from prying eyes.

It sounds easy.  Just eliminate costly unnecessary care and save the system.  While you are at it, why not bring world peace, eliminate poverty, and make a detergent that cleans, softens, and deodorizes all at once?

Yes, the problem is daunting, but the only way we can get out of the financial vortex we are in is to cut the cost.  Between the two, I favor eliminating unnecessary care over that which is necessary.  I suspect most of my readers share that emotion.  So, like peace and poverty, we need to take a bunch of smaller steps on the way to solving the problem.

But hold on, campers, I am going to pour a little water on your campfire before we all start singing Kum-By-Ya.  I don\’t think all unnecessary care is bad.  Yes, you read me right, I think that sometimes it is a good thing to waste money.  I\’ve personally given \”unnecessary care\” several times over the past few weeks.

One time I did it was when I sent a man to hospice.  Hospice itself saves a tremendous amount of money, keeping the cost of end-of-life care under control while giving the patients maximum comfort.  But typically, you don\’t give drugs to prevent long-term problems to patients with a short-term life expectancy.  This man has been my patient for a very long time, and has been on the blood thinner Coumadin for the entire time I\’ve cared for him.  He\’s always been very aware of his lab results and the need to keep his blood thinned to just the right levels.  He\’s been faithful in his taking of his medication and going for his monthly lab test.  To him, the Coumadin is at the center of his healthcare universe.  So when I sent him to hospice, I didn\’t have the heart to suggest stopping the blood thinner.  It was always part of his self-care.  It was always a way in which he exerted control over his medical problems.  I may be wrong, but stopping the medication would probably leave a gaping hole in his life when I was trying to make him the most comfortable.  I just couldn\’t do that to him.

I\’ve had other elderly patients of the same cloth.  They don\’t resent the need for taking medications; they structure their days around these medications.  I have to give a very convincing argument to them when suggesting that any of these medications be stopped.  I do my best to minimize the length of the list, but I don\’t fight too hard.

Finally, there are the unnecessary or unproven tests.  I now routinely discuss the pros and cons of PSA testing, mammography, and Pap smears with patients.  The older a person gets, the less benefit these tests yield.  But even when I think these tests are not needed, I do give the patients the option to get them done.  Most people are relieved when I get them off of those hooks, but some are uncomfortable.  Some people find comfort in doing something rather than leaving things to fate, God, or whatever.  I do my best to dissuade and educate them, but in the end, the choice is theirs.

I don\’t want to suggest that I do this to most of my patients.  I routinely look at medication lists and remove whatever is unnecessary.  I am a minimalist when it comes to ordering labs, consults, or tests – only getting those I truly believe are helpful.  Most of my patients appreciate this fact, and would gladly live with as little time spent devoted to medical care as possible.  I am probably more aggressive than most in this regard.  But it is dangerous to become too rigid in our view of medicine.  Medical care is not done via mathematical formula or actuarial table, it is done face-to-face between patient and provider.  The care is based on science, but the application of the science is done by humans on other humans.

So what\’s the point?  The point is that care is always, in the end, personal.  I don\’t think we should be spending money on procedures, drugs, or hospitalizations that are not needed.  I do, however, worry that the push toward evidence-based care will start in the wrong place.  The additional cost I add to care is quickly outspent by a single hospital stay, unnecessary surgery, or even ER visit.   Those with the most money to lose in this game of cutting cost will fight the most to keep their ground.  Da Vinci surgical company undoubtedly has scads of lobbyists pushing for coverage of their procedures.  Drug companies will fight to keep the cost of their medications as high as possible.  So who will fight for my patients?  Who will fight to keep my little old man on coumadin when it\’s not needed?

We must cut the cost of care, but beware of what care is cut.  Cut the big-ticket items that drive up cost.  Cut the unnecessary MRI scans, cardiac caths, and the improper use of antibiotics.  Pay only for screening tests that really prevent disease, not just ones that have been hyped by the media.  But let me care for my patients.  After all, the system is about them.

5 thoughts on “The Virtue of Unnecessary Care”

  1. I’m with you. In my group of over 20+ docs, I prescribe the least antibiotics (our clinic watches & tallies this every year) and the least CT scans and x-rays (we watch this, too). I work hard to protect children from invasive testing or screening or meds that ultimately aren’t needed, don’t change what we will do, or doesn’t protect them.
    The big issue in primary care (as I know you know) is the way we are reimbursed. It’s based on production (how many you see versus how well you see them). We don’t reimburse on quality, partly because quality is hard to measure. For example, the only quality metric that our clinic measures for pediatrics are immunizations rates. AND WHEW–let me tell you, that isn’t the measure of a pediatrician’s quality, rather of their practice, their patient population, demographic, and/or their patients’ vaccine-hesitancy….

    You can bill more for a visit when you write a prescription than when you don’t, even though it is easier to say, “Take this Amoxicillin” versus, “I believe the infection is caused by a virus. Your child needs time, rest, and energy to help support their immune system to heal. A humidifier, honey for cough at night and nasal bulb suction.” And the list goes on and on of how much energy it takes to explain NON-INTERVENTION.

    Laziness, fatigue, and burn-out are often to blame for those who write Rx’s all day for viral infections or order unnecessary tests or consults.

    We need to figure out ways to inform, support, and maintain primary docs to do what they do best: listen, examine, educate, and support the patients they care for…

  2. “We need to figure out ways to inform, support, and maintain primary docs to do what they do best”
    No figuring required: just pay them more. Everyone knows that’s the answer and gives it lip service, but all the vested interests refuse to allow any action on this.

  3. The biggest problem I see is: who makes the decision on what is necessary and what is unnecessary.
    A year ago, I lost feeling in my hand. My doctor was convinced it was just carpal tunnel. I KNEW it wasn’t. I wasn’t sure what it was – thought perhaps a pinched nerve. But I saw her rolling her eyes. I pushed and to “prove me wrong” she ordered what she thought was an “unnecessary” test – an MRI of my neck.

    The amount of damage to the myelin sheath on my spinal column was a pretty good indicator that I had Multiple Sclerosis. So then there were more tests – an MRI of my brain, an MRI of my lower back to see how far down the damage was, an LP to get proof of diagnosis. Yup. MS.

    Were these tests necessary? Unnecessary?

    And what’s more, regardless of whether the doctor thought they were necessary, what would the government say if they were in charge of making that decision? Were my symptoms impacting my ability to be an active member of society? Not yet – I just didn’t have any feeling in my hand, but I could still use it. If they had been in charge, would I have been able to get that test? Probably not. Not until the MS had continued to the point where it started to become debilitating. And then, my prognosis would be for crap.

    As it is, I have barely any symptoms, I’m on a medication that’s designed to impede the disease’s progress, and my prognosis is pretty bright.

    So eliminating “unnecessary” care is fine. But if you don’t answer who determines what is necessary, you’re not answering the whole question.

  4. There’s another side to EMR, beyond the advantages you sight. In most systems, certainly ours, it distills the documented patient visit into a point and click experience. Of course, this impacts on patient rapport, but many of these lengthy computerized documents are filled with fluff and silly data. I often review them and try to divine what precisely are the patient’s symptoms and what is the physician’s assessment. They are not designed by folks who understand how physicians operate at ground zero and what our needs are.

  5. Rob
    As we’ve discussed before, I use an EMR in my telepsychiatry job and love it. Care to ED patients all over the state is faster, more efficient, and saves thousands of dollars in unnecessary hospital admission costs. In my part time clinic job, the EMR is also used. In my Crisis Unit coverage, docs still dictate H&Ps but write out everything else (another state system).
    In this economy, where so many of my emergency patients are driven to suicidal and even homicidal thoughts due to unemployment and other economic concerns, prescription of affordable care (tests, meds, all of it) is paramount. Just yesterday afternoon, I accessed the costs of brand versus generic meds for a working single mother of a baby. Her agitation and anxiety were threatening to significantly impact her job. Point of care access through Epocrates on my iPhone enabled me to find the least expensive alternative that we knew she would buy and use. I felt that I had really helped her reach HER goal in meeting her, personally and economically, where she was in her life.
    These are tough times. Sometimes I feel that if I am the best one person system of care I can be for that one patient sitting in front of me, that’s my mission for now.
    Thanks as always for the thoughtful post.

    Greg

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