Too Much Care

In a recent article in the NYT Dr. Sandeep Jauhar, here, discusses, quiet eloquently, some of the causes and effects of too much care. For further, more in depth reading on this topic I highly suggest Shannon Brownlee’s book “Over Treated”. I would like to go just a bit deeper into the subject.
The causes of too much care are vast and interrelated, however I do agree with Dr. Jauhar that the major cause is economic, having run my practice such that I minimized the amount of treatment and intervention, thus cost (thus further my profit) I suffered financially. I of course did this because it is what is in the best interest of the patient…….or is it? Dr. Jauhar’s cardiologist friend from Long Island took the other half of this argument. The justification is this, if I don’t make enough to continue to practice the community will actually lose an important commodity? In fact when I closed, 1500 patients were left without a doctor, and in a community with a shortage, many had to wait months to get one and had to travel much further away. I will leave it up to you, which is right, more care for survival of the practice such that care can continue to be provided (albeit at less quality), or proper care for the individual? Now, the eight main reasons we are getting too much care.
#1 ECONOMIC, That’s right, you are getting too much care because hospitals, and doctor’s offices can not sustain if they don’t provide these unnecessary, expensive and often dangerous treatments and interventions. The pharmaceutical industry on the other hand is providing this in the name of pure profit, survival is not an issue, not to say that some of the docs and hospitals are not specifically profit driven, but overall, less so.
#2 DEFENSIVE MEDICINE, Without a doubt defensive medicine is happening (that is ordering tests, and investigations not based on science or statistics, but based on, “just in case” or so “I don’t get sued”) the problem with this is that docs are often unwilling to admit (at lease publicly) how much of this that they do, thus there is absolutely no way to discern how much it is costing all of us. Read my piece on Liability here.
#3 MISPERCEPTIONS, The misperception that more care is better care, this “is” a misperception. The studies reveal that where there are more specialists and specialty care, life expectancy is shorter. Dr. Jauhar’s friend gives a nice example of how this affected the cost of medicine in his practice/community.
#4 PRIMARY CARE SHORTAGES, whether you think there is a shortage or not, there is. In many communities there is a long wait to get a doctor, and to get an appointment. This is tied tightly to economics, primary care gets reimbursed the least for what they do, thus if you own a practice or hospital you want to own some specialists and “encourage” your primary care providers to “provide less and refer more”!! With long hours, low pay, and often little respect, the number of medical students opting to go into primary care is ever shrinking. More specialty care obviously means more tests and more interventions.
#5 HEALTH INSURANCE, The health insurance industry adds nothing of quality to health care; they do however add overhead costs to the doctor’s office via, complex billing procedures and prior authorization requirements. Health Insurance companies spend 70-85% of premiums on health care; however that also means that 15-30 cents on the dollar of your money goes to CEO salaries and unneeded overhead expenses. With higher overhead, doctors and hospitals are forced to perform more expensive tests/procedures to pay the bills, more on overhead here.
#6 GOVERNMENT INTERVENTION/MANDATES, Yes, though I personally believe that a single payer system is the most equitable way to spend our health care dollar, I am not blind, it is clear that govt mandates on health care and insurance have increased the cost of providing care (in this profit system that means the cost of doing business) without providing means to pay for it. I have written at TPM café about this, read the section called band aides and props if you are interested, and if you can find it. Again, anything that increases the cost of doing business increases the likelihood of doing more expensive tests and procedures.
#7 MARKETING, That’s right, marketing increases what we spend on medical care, most notably through the pharmaceutical and medical device industry but this applies throughout. Of course more contact with the doctors and hospitals because the TV told you that you might have “blank” leads to testing, intervention and treatment. Without providing an incredibly detailed argument, if marketing did not increase income (in this case money spent on health care, meds etc) no one would do it.
#8 TOO MUCH CARE, more care begets more care, one abnormal test leads to another, leads to a complication which leads to an intervention which leads to…………

I was going to go into the effects; however, my usual verbosity has inspired me to shut up now. Please note however, that anyone who purports that it is only one or two of the above causes that leads to increased cost of health care, and or the increase in testing and overall decrease in quality of care is standing in the middle of a forest and blaming a single tree for getting them lost.