Tuesday, October 24, 2006

Working Harder, Not Smarter, in Medicine

In today's Wall Street Journal, Dr. Benjamin Brewer gives as succinct a statement of the morass of treatement incentives in the practice of medicine as you will find:

One of the problems with our medical system is the bias to pay doctors more for performing a test or procedure than for using our heads to make a diagnosis or manage a disease.

Obtaining a thorough history and physical exam and reviewing tests to make a challenging diagnosis pay much less than conducting a battery of tests or performing a diagnostic procedure.

If I spend 30 minutes in an extended office call for a patient with diabetes, high blood pressure and heart disease, I get paid an average of $69. If I remove a skin cyst off the patient's back in that same time, the minor surgery would bring $110.

If I do a screening colonoscopy at the hospital to check for colon cancer for the same patient in the same time, my average reimbursement is $478 with essentially no office overhead. It's no wonder that medical students want to go into procedural specialties like gastroenterology and fewer want to pursue cognitive specialties such as general medicine.

Fascinating. As always, there are tradeoffs involved. There are two types of errors that can be made with respect to procedures: they can be implemented when they were not medically necessary or they can be not implemented when they were medically necessary. As a society, we put a lot of weight on avoiding the latter type of error. The field of medical malpractice exacerbates this. So it is not surprising that we have poor safeguards against the first type of error given the high fees. But if we tried to improve them, we should expect to have more of the second type of error.

Brewer's point about choice of specialty is also a good one. After we had the VoxSon, it became very clear to me that the medical industry tremendously undervalues and undercompensates pediatricians, who epitomize the need for using their heads rather than tests.


Rob Dawg said...

Ignorance? Anticipation?

Anonymous said...

Absolutely. It's natural for our health care system to tolerate a higher rate of false positives when people's health is at stake. You probably read it, but David Leonhardt had a column in the NYT a week ago about this. He pointed to unnecessary medical procedures as the major factor inflating health care costs in tha US.

I think there's also another reason the medical establishment would rather Dr. Brewer ran a "battery of tests," which is that it's...scientific. A fundamental precept in the medical research community is that a diagnostic procedure which can be validated and standardized is preferable to an expert's opinion. (To me that seems obviously preferable, but I just read Alex Tabarrok write the other day that this scientific approach to medicine is "[a] still far from accepted movement"!)

Not that there aren't systematic methods of assessing someone's medical history and test results (like Dr. Brewer wants to do in his office) that would be cheap, fast, and effective. But they aren't going to be trusted by the research community until the methods eliminate inter-observer variability.

Anonymous said...

Personally speaking, I've had better luck in being correctly diagnosed in 15 minutes by a doctor sitting in a street corner shop in India than having gone through a battery of tests over an 18 months in California, with no conclusive diagnosis from the doctors. Now I simply prefer to make a month-long trip to India for serious health problems than go through the frustrations of american health and insurance system. Its way cheaper and faster. Having seen the health systems in US, India, and Europe, I believe that throwing technology at the system doesn't necessarily help make the health system better - it only makes it expensive. Without the wide human experience in dealing with range of health problems or the cognitive ability to put two and two together, the doctors in US are some of the least competent lot I have seen...but that's just my experience of course. My advice would be to have every doc take a year-long internship at one of so-called third-world countries - that alone would improve their quality several fold.

P. J. Grath said...

All those tests employ huge numbers of people (good) and at the same time drive up the cost of health insurance so that those without insurance are further than ever from being able to afford it (bad). Then, of course, there's the not-having-to think part: good or bad? What an irony that more and more science leads to less and less thinking.