Stanley Feld M.D.,FACP,MACE
The Role of Physicians in Controlling Medical Care Costs and Reducing Waste by the RAND Corporation and David Geffen, University of California Los Angeles School of Medicine, Santa Monica was just published in the Journal of the America Medical Association (JAMA). I do not think the JAMA should have published this article.
1.Why would the JAMA publish such an article?
2. Why are physicians blamed for all the waste in the system?
3. Why is it the physicians’ responsibility to eliminate waste when they are not the cause of the greatest percentage of the waste?
“The amount of money spent on medical care is increasing faster than the gross domestic product (GDP), and the federal deficit is increasing.”
The initial statement assumes that the government deficit is increasing because physicians control government spending for healthcare.
This is only partly correct. The question I have is maybe patients should drive medical costs and not the government.
The government bureaucracy and the healthcare insurance industry has created this cost monster.
“Budget experts believe that the deficit cannot be reduced unless medical spending can be controlled. What role will physicians play in controlling health care cost growth? Are physicians even willing to play a role?
The article outlines the steps physicians must take to reduce waste and therefore the budget deficit. The assumption is physicians are the main source of the healthcare system’s waste.
The RAND Corporation does not consider the waste of the government bureaucracy, the healthcare insurance industry’s excessive fees, the hospital systems’ excessive billings, nor the pharmaceutical companies excessive charges for medication. Not considered is the excessive waste that results from the forced practice of defensive medicine because of the lack of tort reform.
If all these issues were addressed, waste and costs would be markedly decreased. There would be no need to try to commoditize physicians’ medical decisions.
I cannot visualize success in trying to commoditize the physician’s decision-making processes.
The healthcare system should be consumer driven with the consumers owning their healthcare dollars and making their own healthcare decisions. The government must help teach consumers to make appropriate medical care decisions with their own money. The government could provide the money. It would eliminate all the bureaucratic waste and secondary stakeholder abuse because it would create a true marketplace driven by consumers and not an artificial marketplace driven by government inefficiency. Consumers must make their own medical care decisions and be responsible for their actions.
The authors of the article suggest that physicians have three options for participation in controlling healthcare costs. The problem is it assumes the burden for controlling costs are the responsibility of physicians.
1. "Physicians can do nothing."
2. "Health care can be rationed."
3. " Physicians take the lead in identifying and eliminating waste in US health care system."
4. (We have tried to lead.)
5. (President Obama has ignored us.)
“Physicians could define waste by assigning all services to 1 of 4 types of care—inappropriate, equivocal, appropriate, or necessary”.
This is subjective busy work that is destined to fail. It will also stifle creativity, thinking, problem solving and innovation.
Physicians try to practice evidence-based medicine. There are defects in determining best practices. In many cases the conclusions drawn from clinical results are inaccurate. It is arbitrary based on the bias of the experts picked to be the judges.
1.Inappropriate care, the potential health benefit to the patient is less than the potential harm caused by the procedure, device, or drug
2. With equivocal care, potential harm and benefit are about equal.
3. With appropriate care, potential benefit to the patient exceeds potential harm.
Necessary care is appropriate, represents the only viable option, and produces a large health benefit.
Who decides appropriate and necessary care?
An excellent example is the difficulty deciding appropriate and necessary care in the use of post-menopausal hormonal replacement therapy. The study design of the Women’s Health Initiative (WHI) was defective, the execution of the study was ineffective and the statistical analysis was inaccurate. The conclusions of the WHI are suspect. Yet the WHI has been heralded as evidence based medicine for best practices. It has changed the course of women’s health forever.
A tool to measure clinical waste across all clinical services does not exist. This is because the definition of “clinical waste” is ever changing. Today’s best practices can be tomorrow’s clinical waste.
Physicians are constantly trying to define best practices. It must be the job of physicians. Physicians are constantly trying to teach other physicians best practices. Physicians are constantly trying to learn to keep current.
The best practices have to be put into context with changing scientific concepts. Potential bias must be evaluated.
The clinical decisions should not be the interpretations of policy wonks or bureaucrats.
None of this is black and white. Policy wonks, economists and bureaucrats have little understanding of the complexity involved in clinical decisions.
Their interest is to somehow try to quantitatively measure physicians’ clinical decisions against an artificially created set of standards defined as waste.
“Physicians prefer the medical definition. But it is not known how much clinical waste is in the system.”
Another excellent clinical example of the controversy is the treatment of choice for Graves Disease (hyperthyroidism). There are cogent arguments for the treatment of choice for Graves Disease with either radioactive iodine or medications such as PTU or Tapazole. There is no unequivocal scientific evidence for an advantage of either treatment.
Attempts have been made to prove an advantage of one treatment over the other. When there is a lack of unequivocal evidence for best practices, patients must be given a choice of therapy.
A defect in the attempts to determine best practice in clinical research is the elimination of patients’ freedom to judge and choose or participate in the best treatment choice for that individual.
It is physicians’ responsibility to defend and maintain that freedom for their patients. The reasons for waste in the healthcare system should not be determined arbitrarily by bureaucrats.