Doctors Offer Thoughts on Cutting Health Care Costs

Doctors Offer Thoughts on Cutting Health Care Costs
By LESLEY ALDERMAN
Copyright by The New York Times
Published: March 20, 2010
http://www.nytimes.com/2010/03/27/health/27patient.html?hpw


IN persuading Congressional Democrats to pass the health care overhaul, President Obama addressed one of the most pressing issues facing the country: providing broader access to medical insurance for as many as 32 million Americans who do not now have it.

For many of the rest of us, the benefits could still be substantial once the law takes full effect in 2014. People with pre-existing medical conditions could no longer be denied insurance. All lifetime and annual limits on coverage would be eliminated. And new policies would be required to meet higher benefit standards.

But the new law does not tackle head-on the staggering cost of health care in the United States, which eats up $2.3 trillion a year, about 16.2 percent of our gross domestic product, according to the Department of Health and Human Services.

That raises the ultimate Patient Money question: How can the country reduce health care costs while not compromising quality?

During the health care debate, government officials, insurers, drug companies and medical associations all weighed in with their opinions. But what about the people who receive so much of our out-of-pocket health care payments: the doctors on the medical front lines? What do they think the country — in other words, you and me — should do to help moderate costs?

I turned to some of the doctors I’ve interviewed over the last year and asked them to prescribe remedies for high medical costs. Here is what they said. (The remarks have been edited and condensed.)

Insure Catastrophes Only

“The idea of paying a certain monthly fee for insurance that allows you to have most of your routine care covered doesn’t make sense. When you buy auto insurance, you don’t insure yourself for every dent and nick — you insure yourself for serious accidents. This is the way the health insurance system should work. Our current insurance model does not encourage patients to take care of themselves. It doesn’t reward patients for being healthy, it rewards them for being sick. This isn’t good for patients or insurers.”

Jacques Moritz, M.D., director of gynecology, St Luke’s-Roosevelt Hospital Center, New York

Change Malpractice Law

“Some doctors often order tests to confirm a suspected diagnosis — even when the suspected diagnosis is likely correct with a high degree of certainty — out of concerns regarding the potential for malpractice suits in our current litigious climate. This is a cost of medical care that could be fixed if serious efforts at tort reform were undertaken.”

James A. Reiffel, M.D., professor of clinical medicine and director, electrocardiography laboratory, Columbia University Medical Center, New York

NOTE: The new law contains a provision to award five-year grants to selected states to develop alternatives to current tort litigation.

Counsel Nutrition

“In the cardiology arena, adoption of a Mediterranean style diet has been shown to reduce the likelihood of a second heart attack by more than 70 percent — a benefit far in excess of any drug or procedure. Unfortunately, most doctors do not have the training to provide effective nutritional counseling. How much does the health care system — and more importantly, the patient — lose every time a medical encounter does not include attention to nutrition?”

Stephen R. Devries, M.D., preventive cardiologist, Northwestern Memorial Hospital, Chicago

Rely on Evidence...

“I believe that if you do the right thing for the patient, it will ultimately be the right thing for the health care system. That means spending adequate time gathering information and using actual research data to guide judicious ordering of tests and prescribing of treatment. For instance, if an asymptomatic, otherwise healthy, patient comes to me wanting a whole-body CT scan to make sure they do not have something bad hiding inside of them, I would decline and educate him or her that there is no data to show that this test has any significant benefit to offset the potential radiation or other harm and the major medical societies do not recommend this test.”

Lisa Bernstein, M.D., internist and associate professor in the department of medicine, Emory University School of Medicine, Atlanta

NOTE: The new law provides for the creation this year of a nonprofit corporation, the Patient-Centered Outcomes Research Institute, which would conduct research comparing the clinical effectiveness of medical treatments. The institute’s findings could not be construed as mandates, though, or used to deny coverage.

... But Allow for Expertise

“Government policy often results in a race to the average and mediocre, to the customary and usual, while ignoring the exceptional and extraordinary. And it is this group of patients — the unusual, the outlier, the complex, the group that has failed evidence-based care — that represents the costliest group in any illness category. Such is the case in migraine, where a very small percentage of patients represent 75 percent of the overall costs. These are the patients who must be hospitalized, who attend the emergency department on a regular basis, who develop secondary illness, undergo needless procedures and surgery, and become dependent on narcotics in their desperate search for pain relief. The pursuit of savings by government agencies often misses the point that good care at almost any price is less costly than bad care at almost any savings.”

Joel R. Saper, M.D., founder and director, Michigan Head Pain & Neurological Institute, Ann Arbor, Mich.

Use ‘Integrative Medicine’

“Plenty of studies now show that integrative medicine works very well. By that I mean the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, and has a broader scope that includes therapies from conventional bioscientific medicine, as well as newer complementary approaches like acupuncture and chiropractic. For example, a study conducted at Mount Sinai School of Medicine in New York found that when women participated in a hypnosis session before breast surgery, they required less pain medication and experienced less nausea and emotional upset than the control group. Patients in the hypnosis group also cost the hospital $772 less overall. That’s an example of how a simple technique can help patients and reduce costs.”

Woodson Merrell, M.D., chairman, department of integrative medicine at Beth Israel Medical Center, New York

Pay to Treat Child Obesity

“We struggle constantly to get reimbursement for services at my clinic. This is terribly short-sighted. Society could spend one thousand dollars now for comprehensive medical care for an obese child, or it could spend one hundred thousand dollars later for that patient’s coronary artery bypass surgery. Every insurance company figures it’s not their problem: an obese kid will likely be with a different carrier by the time he or she starts to experience costly health complications.”

David Ludwig, M.D., director, Optimal Weight for Life Program, Children’s Hospital, Boston

Stop Overtreating

“There are some people who would benefit from more medical care, but there are many more who are getting too much. Excessive intervention is particularly rampant at the two extremes of health: those who are dying, for whom our aggressive care can be inhumane, and those who are well, in whom we feel increasingly compelled to look hard for things to be wrong. There are strong commercial interests in tapping this latter group as a new source of revenue. Screening scans, for instance, find more small cancers and early heart disease. Contracted definitions of what’s normal label more people as having disease, such as hypertension and diabetes. And everyday experiences become entirely new diseases: difficulty sleeping becomes a sleep disorder, impaired sex drive becomes sexual dysfunction.”

H. Gilbert Welch, M.D., professor of medicine, Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, N.H.

Restore the Humanity

“What’s in jeopardy in medicine — for a host of reasons — is the human connection between doctor and patient. There are doctors in training now who do not want to do a physical exam; they just want the lab tests and the echo-cardiogram on a heart patient, for example. But the laying on of hands is a powerful tool in establishing trust and in healing. Doctors, patients and insurers alike should work together to recreate the familiarity, the warmth, the trust and the friendly alliances that used to define patient-caregiver relationships. If the health care profession would rediscover the power of the human relationship, we could bring about the kinds of lifestyle changes that would reduce disease big-time.”

Edward Hallowell, M.D., a child and adult psychiatrist practicing in New York City and Sudbury, Mass., author of “Married to Distraction” (Ballantine Books, 2010)