Monday, May 19, 2008

Over use of health care

That the American health care system is a dream for insurers and doctors, and a nightmare for patients is well documented. Sample the latest chronicle by Dr Sandeep Jauhar in the NYT,
"I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his month long stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist. He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia)."

Dr Jauhar blames over-utilization and over-treatment for the aforementioned state of affairs. Overutilization is driven by many factors - "defensive" medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better. Over consultation and over testing arise from the perverse financial incentives that face doctors.

Contrast this with the present situation in India, despite its rapid convergence to the American situation. Medical diagnosis in the US is largely an exercise in technology based, mechanistic filtration, while in countries like India it still is a function of the doctor's professional judgement and clinical skills. Patients in the US are, for a variety of reasons, subjected to all possible diagnostic tests before finalizing the prescription. In contrast, doctors here rely on a few basic diagnostic tests and then rely on their experience and clinical skills to make the prescription.

The American medical care system addresses treatment in terms of a theoretical outlook that seeks to rule out all possibilities, thereby explicitly minimizing the role of doctor's judgement. In contrast, the Indian medical treatment approach looks at the symptoms and then tries to rule out the dominant possibilities through a few basic diagnostic tests. This method places considerable importance on the professional expertise and experience of the doctor. It works on the basis of preponderance of probabilities as the basis for making the diagnosis.

I have tried to list out the incetives and disincentives that face each stakeholder in the Indian and American medical care protocols. The American system first.
1. Threat of lawsuits - the doctor decides to play safe and minimize his judgement, and therefore prescribes the full protocol of tests.
2. Reimbursement of treatment by insurance companies - As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. So patients get subjected to more number of tests.
3. Patients demand comprehensive care - leaves the doctor with little option but to conduct the full spectrum of diagnostic tests.
4. High cost of testing facilities - Doctors try to recover their high investment costs on diagnostic equipments by maximizing on the numbers of tests.
5. Piecemeal payments - Doctors get reimbursed for whatever they bill, thereby incentivizing them to over test and over consult.

1. Payment detached from treatment - Patients do not pay separately for each diagnostic test, making them unaware of the actual cost of their treatment and tests.
2. Feeling that technology and comprehensive testing is better - Increases the pressure on doctors to do the full spectrum of tests.
3. Ease of access to testing facilties - incentivizes the demand for testing, leading to over-testing.

Insurance companies
1. Threat of lawsuits - insurance companies insist on the full spectrum of diagnostic tests, so as to minimize the role of discretion and judgement.
2. Moral Hazard concerns - transaction costs go up, reflecting in higher premiums.

Contrast this with the Indian system where the major share of patients do not have any insurance cover.
1. Get paid by the patients - incentive to minimize costs.
2. Patients demand more personal care - incentivizes doctors to trust their clinical skills and judgement.
3. High costs of diagnostic tests - incentivizes doctors to minimize tests.
4. Predominance of single doctor hospitals/clinics - minimizes over-consultation.
5. Not very active medical litigation market - encourages doctors to make diagnosis and make prescriptions trusting their judgement.

1. Demand for personal care - patients have to trust the doctors
2. Patients choose their doctors, and makes direct payment to the doctor - this introduces competitive pressures and lowers costs

Health care is very unlike any other service delivered in the market, which obeys the traditional principles of economic analysis. In the final analysis, any health care system can be efficient and effectively deliver its desired objectives, only when the patients have adequate faith in the doctor's diagnosis and the doctors have enough trust in their own clinical skills and experience to make definitive judgements on the final diagnosis. Health care policies need to have incentives and disincentives that promote this re-establishment of trust and belief. Ironically enough, the spiralling health care costs may just about be getting out of control, thereby providing a very strong reason for patients to go back to trusting the judgement of their doctors.

The Slate has an article by Dr. Darshak Sanghavi who argues that doctors in the US are simply not focussed on treating the disease. He adduces two reasons for this deficiency
1. Clinical training in primary care excessively focuses on the diagnostic hunt rather than the more routine rounds of treatment that follow. Medicine is about the exciting search for a diagnosis, and any old doctor can write a prescription once the real work is done.
2. Medical education today fixates on acquiring knowledge that is largely unrelated to patient care. The sheer abundance crowds out an important—in fact, the only—skill that matters in treating a patient: how to critically appraise published clinical trials. Few doctors ever read them. In effect, medicine has become a priesthood of practitioners who never review or learn to interpret the Bible to minister to their flock; they instead rely on secondhand wisdom.

Therefore, as Dr Sanghavi says, "the average internist can describe the branching patterns of the major coronary arteries but not the primary clinical trials assessing how much, if at all, various cholesterol-lowering agents cut heart-attack risks. Or, for that matter, whether the trials were soundly conducted."

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