Saturday, April 05, 2008

Overuse of Medicine

Via Newmark's Door, here's a NY Times story on some of the incentives that lead to the overuse of medicine:
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong 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).

Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.

This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: 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.

* * *

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.

The most important factor, however, may be the perverse financial incentives of our current system.

* * *

Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.

“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.

“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both from a financial and a reputation standpoint.”

His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.

“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”

“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”

He shrugged and said, “That is what I have to do to break even.”


Blogger miriam sawyer said...

Life expectancy and infant morality statistics are affected by lifestyle habits, rather than the availability of medical care.

Alcoholism drug abuse, and obesity are major factors.

1:57 PM  
Blogger Unknown said...

I am one of such patients given an Nuclear Stress Test that was unnecessary. All of my bloodwork, chest xray, and EKG came back normal. The Dr. insisted I have a Stress Test and mentioned there was an injection..I told him I did not want Dye..he assured me "There is no dye, and it is a completely safe test". I asked three of the staff; the Dr., a Nurse on cardiac floor, and radiologist, what this test was, the risks of it, etc. I was told "it was completely safe", finally told it was radioactive pharmaceutical, but, equivalent to "ONE" chest xray. I have since found out that ONE Nuclear Stress Test (Cardiolite) is the equivalent of up to 1,000 chest xrays and carries risk of long term fatal cancer from one exposure. If I had been given accurate information about this test, I never would have had it. It is abusive and criminal that patients such as me are lied to and their lives put at risk to pay for expensive equipment.

10:49 PM  

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