Medical Cost

A neglected area of my medical education:

The cost of medical treatment.

We learn so much of medicine in our four years of medical school. In our clinical training, we’re taught to order labwork, consults, imaging, pharmacy—everything we will use as tools to choose in our treatments as physicians. Price tag not included. It’s like a mastercard: at the end of every tallied bill, the overall result is priceless. Right?

I had this image in my mind when I started medical school that as a doctor I would be very self-sufficient, a leader and independent healer in my community. I wanted to be able to go to any corner of the world and help people—cure them of disease. This was incredibly naïve in many respects, in large part because medicine isn’t only a relationship between a doctor and a patient any longer. My knowledge and skills are not very useful without the tools I am trained to depend upon: lab values, imaging, procedural equipment, and hospital staff to carry out my orders. In my reliance on these tools, I’ve lost a large portion of autonomy in my patient relationships. I can’t donate my care, for example, without also asking my clinic staff to donate time, my clinic to donate facility charges, and the lab or hospital network to donate diagnostics.

Anything I’ve learned about how my work will be reimbursed or what charges a patient will incur due to my decisions are things I have learned outside of my medical school curriculum. These are lessons from friends and family, patient complaints, medical bills and political controversy. At the free clinic where I volunteered, we use a Wal-mart $5 pharmacy list and carefully select imaging based on cost. Barium enemas, at up to $500 dollars can be used in the stead of colonoscopies at up to over $6,000 a pop (I got these figures from a google search—all I knew was that colonoscopies were more expensive!).

In Canada, any citizen walking into an Emergency Department or clinic will receive healthcare. This comes at a cost in the form of taxation—and sometimes a longer wait for non-urgent consults, testing, and services.  There are good and bad things in this system, but during my time there I found it was a system that I preferred.  Overall, I really was inspired by the attention to medicine, thinking about diagnoses and careful, detailed physical exams with thoughtful ordering of diagnostic tests rather than a battery of tests to do the diagnosis for you.

The physicians with whom I worked in Nipigon were salaried. In the U.S., most physicians in clinic are reimbursed with relative value units (RVUs)—a predetermined scale that decides in advance what remuneration is warranted for each visit. The higher the complexity of the visit, the more can be charged. The more tests and images ordered, diagnoses coded, items checked off on a physical exam—the more the doctor is reimbursed. Procedures are rewarded more than preventive health or discussions with a patient regarding their health. This is interesting to me as most physicians would agree that, for example, a discussion with a diabetic patient to control their blood glucose is much more difficult than injecting an arthritic knee with steroids. Relative value units, however, reimburse the latter at a higher level. (An interesting new payment model is piloting in the Ballard Clinic with the Swedish Cherry Hill Family Medicine Residency in Seattle.)

I’m not suggesting that docs base all their decision-making on how to pump more money out of an encounter, but it is interesting where incentives are placed. Wouldn’t it be nice if incentivization fell along more ethical lines? Supported reining in costs and unnecessary tests and limiting unnecessary procedures? Wouldn’t it be nice if patients could have time spent with them over the telephone (rather than being asked to schedule appointments because appointments pay), or a few extra minutes in an office visit to follow up on their concerns—and these were not just uncompensated nuisances in a busy clinic schedule, but recognized in reimbursement as a part of vital patient care? It isn’t that things are always mercenary or that doctors consciously think in this manner, but I find the reward system to be ethically lacking. 

No one wants their doctor to make decisions based on cost. No one wants to cut corners when it comes to their own life. Who will make these decisions, since individuals cannot (resources are not unlimited). "Death Panels" have been decried by members of our country, but these "death panels" are trying to ethically distribute limited resources for a greater, more equally distributed, good--to promote increased health and longevity. Why not "Life Panels"?

Doctors practice what we call defensive medicine, protecting themselves from potential misdiagnoses and subsequent lawsuits by pursuing every imaging and laboratory option (in less litigious countries like Canada, some doctors argue, they would not need to order so many tests).

It’s an industry where cost is not considered, and everyone wants a cut: medical professionals, legal professionals, medical suppliers and pharmaceuticals, hospitals, insurance companies. The end result are spiraling costs and one of the biggest industries in the world.

Yet, everyone wants to rein in costs. How do we strike this balance? What should we be teaching about costs? How can we prevent frivolous lawsuits and ensure that people injured through medical malpractice receive reimbursement? How can we decrease the excessive profits of hospital systems, some physicians, and insurance companies while keeping competition to drive prices down? How can we keep productivity in a more socialized healthcare system? How do we prioritize saving an individual and caring for a world of people in a setting of limited resources? Who should be making these decisions? Politicians? Doctors? Patients?

This isn’t a new discussion and these aren’t new questions. There are many answers—many countries, including ours, have tried different solutions—none of them perfect.

So what changes can we make? Where do we start? I think a good place would be increasing awareness of costs. I want—in my training—to be aware of price tags. I want to see the bills my patients receive—the facility costs, the insurance coverage, the supplies, and tests, and what it costs to receive my services.  I think many other changes will occur in time as costs spiral out of control and we are forced to find solutions, but I think doctors will become a bigger part of these decisions if we can be more aware of the problems.