Wasteful Medical Spending

The state of Washington decided to explore wasteful medical spending in the medical field and identified $282 million dollars spent on testing and procedures which are considered wasteful and harmful. That’s $282 million spent from June 2015 through June 2016 on 2.4 million insured individuals.

They titled the study “First, Do No Harm” which is wet slap in the face of any clinician. The study was done by the Washington Health Alliance and you can read the entire report at the pdf link provided.

I’ll save you the read and tell you that the studies and interventions which were identified were all truly wasteful, no arguing there. I’ll summarize a few key things about the report and then I’ll discuss the ramifications of such a study on our profession as physicians.

 

Summary Findings

45% of healthcare services provided by clinicians were considered wasteful by this report and I’m sure that was still conservative. 1.3 million patients incurred the costs of these wasteful interventions from a total of 2.4 million patients who were treated during this timeframe.

90% of this wasteful medical spending comes from the following 11 measures:

  1. excessively frequent cervical cancer screening
  2. preoperative labs for low-risk surgeries
  3. unnecessary imaging for eye disease (visual field, retinal imaging, etc.)
  4. annual EKG’s for asymptomatic individuals
  5. prescribing antibiotics for URI’s or ear infections
  6. PSA screening for prostate cancer
  7. Vitamin D deficiency screening
  8. imaging for low back pain
  9. EKG, CXR, PFT’s screening prior to low-risk surgery
  10. cardiac stress testing
  11. imaging for uncomplicated headache

 

The Call To Action

I decided to include this study’s Call-to-Action recommendations because for anyone who works in the medical field this should be quite jarring.

  1. criterion for high quality care should be the appropriateness of a study
  2. clinical leaders and medical specialty societies should lead the effort
  3. “choosing wisely” should be the bedrock of provider-patient communication
  4. remove payment incentives for physicians to do more
  5. value-based provider contracts should also measure overuse and not just productivity

 

There is this nifty Health Waste Calculator that was used to generate this report after a bunch of nerds entered all the relevant data and I wanted to include a few other recommendations which I thought would be entertaining for front like physicians.

Remember that these are all considered to be the main contributors to wasteful medical spending.

  • avoid antibiotics for viral pink eye
  • avoid antibiotics for tympanostomy tube otorrhea
  • avoid antibiotics for uncomplicated acute otitis externa
  • don’t order EKG’s for low-risk patients about to start an exercise
  • don’t order unnecessary DEXA scans
  • don’t order/perform unnecessary colorectal cancer screening
  • don’t perform unnecessary coronary angiography
  • don’t order CT’s/MRI’s for simple syncope
  • don’t order routine IgG or IgE testing for allergies
  • don’t obtain imaging for patient with acute rhinosinusitis
  • don’t perform brain imaging for a simple febrile seizure
  • don’t perform sperm testing for initial evaluation of an infertile couple
  • don’t get routine head CT for severe dizziness
  • don’t get an abdomen CT for someone <50 with hx of urolithiasis presenting to the ED for something that’s likely the same
  • don’t get CT for routine evaluation of abdomen pain
  • don’t get echo or cardiac testing for low/medium risk patient with known CAD for pre-op
  • don’t prescribe NSAIDs to patient with HTN, CHF, or CKD
  • don’t schedule elective C-section for patients <39 weeks
  • don’t perform arthroscopy for knee osteoarthritis

 

National Wasteful Medical Spending

It’s really hard for the average person to understand such high numbers such as the $282 million value for the state of Washington in one year.

$282,000,000

That’s the equivalent salary for 1,128 Urgent Care doctors.

It will be even harder to understand the $765 billion value of wasteful medical spending that takes place annually in the US.

$765,000,000,000

That’s the equivalent annual salary for 3 million physicians.

To put the $765 billion value into perspective, that’s about 1/4th of how much we spend on all US healthcare annually. I’m sure far more than 1/4th of our medical spending is wasteful but let’s go with what the ‘experts’ say.

As a Family Medicine physician I order about 90% of the tests which are deemed wasteful. Perhaps not on an individual level but my specialty is certainly responsible for this.

 

The Discussion

How did telehealth become viable and as popular as it has?

Did physicians protest and beat down the doors of congress to allow it to happen?

Shit no! We have no desire to dehumanize medicine any more. Oh and by the way, thanks for the chaperone idea – that one really helps my credibility with patients.

In a capitalist country the majority of services survive because of consumer demand. Except that in this case the consumers are patients who want easier access to prescription medications, works notes, imaging tests, lab tests, and referrals.

Upper Respiratory Tract Infection

After 10 years of practicing medicine, the only URI issue I had was with a patient who had flu-like symptoms and ended up with respiratory failure in the hospital.

This patient complained to my medical group that had I given her Tamiflu then she wouldn’t have ended up in the ICU. Fortunately she did well and recovered 100% and discharged.

I remember that week even though it was years ago because it was quite stressful getting that initial complaint and even worse having to deal with my medical group’s investigation.

I can write a book on URI’s so I won’t go into it any further. But if you are a practicing Family Medicine or Urgent Care physician then you know that the majority of wasteful medical spending is driven by the patient or the pressures of the medical system.

Why would I want to whip out my prescription pad and write something extra?

Why would I want to click on more buttons to order a medications?

Why would I want to type more or dictate more into my EMR to document antibiotic dispensing?

Why would I want to be contacted by a pharmacist who is worried about a medication interaction?

From the above, Call-to-Action #3, it’s almost a joke when you read the report’s full statement regarding this point. It’s as if they live on a different planet, recommending a Sci-Fi scenario where doctors sit down and offer evidence-based facts to the patient and therefore make the best decision for the patient.

Pink Eye & Ear Infections

I have never had a 12-year-old argue with me when I tell them that their pink eye is viral and will resolve on its own.

The same goes for a teenager whom I diagnosed with acute otitis media or externa and tell them to suffer through it and suggest OTC or home remedies.

It’s not these trusting teens whom we have problems with, is it? It’s the $@#% parents, the real consumers of healthcare – those lovely, make-me-wanna-choke-them parents who under the pretence of worry are pressuring Urgent Care doctors to prescribe antibiotics.

If I don’t prescribe it then I deal with a patient complaint or an irate parent at best. I’d possibly have to deal with a lawsuit if the kid gets septic and dies or his goddamn eyeball falls out.

I don’t get a pat on the back, I don’t end up in a national database where I get annual BJ’s for not prescribing antibiotic drops for pink eye.

Have you tried telling a parent to skip antibiotics for an ear infection? Seriously, I feel like I sometimes am practicing in a bubble and then I come to read such reports and realize that we are very disconnected from reality.

 

Standing Alone

I am not trying to have anyone pity me as an Urgent Care physician but I am currently crippled by a 1-year-long medical board investigation and got fired from my medical group for something benign – wrong, but benign.

All the while these guys are sitting there and suggesting that I don’t do an annual pap smear on a woman who would lose her shit if I told her that annual paps are no longer necessary.

Nobody will feel sorry for a physician despite our burnout rate that’s higher than that of any other profession, despite our high student loan debts, despite the ever-complicated EMR’s, despite having less and less time per patient, and despite being one of the highest taxed individuals in the US.

Don’t feel sorry for me but don’t create data which places more pressure on me as a physician. I realize that the patient doesn’t need the EKG, I realize they don’t need the Vit D level, and most definitely not a PSA.

The problem is that I have to suffer even more just to say no. Not only is the process of saying no painful but there are customer service factors to consider as well as potential poor outcomes.

Tell me, when I go before the court in front of a jury and they ask why I didn’t get CT for that abdomen pain that ended up being a fatal ruptured aneurysm, will the jury think “Oh, he was just trying to minimize wasteful medical spending – how noble.” Or will they believe the medical expert who claims that a patient with abdominal pains in the Urgent Care obviously should have had further studies done rather than just get sent home.

Or… or… let’s say it went to court and I got a favorable outcome or that my medical group settled with the patient’s family, how will I get the time and emotional loss back? Will someone hold me and hug me and apologize and then help me reintegrate back to seeing patients without fearing another such dehumanizing process?

Will I care about $282 million of wasteful medical spending when each year 20,000 malpractice cases are being tried across the US? Not to mention the internal investigations – not to mention the medical board investigations?

What’s the cost of all that drama compared to wasteful medical spending? Sure, it’s a separate topic but at the center is the consumer and the consumer is the driving force behind our actions.

 

Patient Resources

The Choosing Wisely campaign has been going on now for 5 years. The link I provided provides information for patients so that they can be a part of the discussion of decreasing unnecessary testing and antibiotic prescribing.

I am aware that there are many individuals who are privy to such information and avoid the US healthcare system or minimize contact with physicians because of the many problems that we cause. However, once again, it’s not those patients I worry about but the ones who walk into the Urgent Care and are the 20% who use 80% of the resources.

Reviewing the Patient Resources tab on that site, it’s clear that the information is incredibly superficial, written at a 4th grade level. It’s uncommon for such information to reach the right people.

The section on Antibiotic Use in Hospitals is sort of comedy, completely missing the target. If this information is meant to empower the patient then it fails to do so. In fact, it creates even more fear because it makes the patient realize what they didn’t know.

That website uses terms such as ‘broad spectrum’ when patients use terms such as ‘strong’ or ‘double the course’ to signal needing stronger relief.

 

Mainstream Medicine

For those of you stuck in OR’s all day and less sensitive feelers for what’s going on in the Primary Care outpatient setting, it’s helpful to understand that not even mainstream medical practices are up to par.

That’s why I make the claim that far more than 50% of what we do is wasteful medical spending.

Strep Throat

We give oral antibiotic for Strep Throat which often isn’t necessary.

Our complication rates of developing Rheumatic Fever in the US are too low to justify out aggressive management of such infections.

UTI

Even a UTI doesn’t always need antibiotics and can be managed conservatively depending on the symptoms.

These misconceptions that untreated UTI’s become kidney infections or untreated colds become Pneumonias are silly.

Acute Sinusitis

Acute Sinusitis is earmarked as anything lasting more than 10 days – ridiculous, absurd, and childish! If it was that simple then why do we need doctors? Just have the antibiotics dispensed by a machine when a patient enters the right criteria.

When I get a sinus infection it lasts about 2 months. I manage it conservatively and it resolves. The benefits I get from not taking antibiotics and just suffering with it for 2 months far outweigh the shotgun approach of antibiotics. Not to mention all those shitty OTC meds which have numerous side effects.

Vital Signs

We measure absolutely unnecessary vital signs in the exam room on a regular basis. We have added the pain scale just to make pain a bigger problem than it already has become in this country.

We still recommend ‘no seeds’ for patients with diverticular disease even though it doesn’t play a part in creating diverticula nor causes the infection of these outpouchings.

I can go on and on. The point isn’t to demonstrate what I know because knowledge isn’t the issue as I hope I demonstrated. A physician need to only practice for a few years until they come across the patients who routinely treat their UTI’s at home and recognize that their sinus infections are in fact sinus allergies.

Penalizing

In the end I am penalized for what I miss and poor patient outcomes if  I don’t offer timely intervention. There is no balanced scale that counts the many times I saved a patient an unnecessary test to offset the one time that I didn’t deliver antibiotics on time.

How deep does this discussion go? Very deep; it has to do with the quality of life that patients want to live and it has to do with our society’s longevity fetish and the absurd monetary value that we have placed on a human life.

2 decades spent on chemo and medication and surgeries in and out of hospitals is considered to be of higher value than spending 2 final years in relatively good health and enjoying every minute of one’s life with friends and family and nature.

Art of Medicine

How do I document in the chart that I ‘feel’ that this UTI isn’t serious enough to warrant antibiotics?

How do I document that I ‘feel’ that a 2 day course is sufficient to treat this puncture wound to prophylax against an infection?

You can’t.

Physicians aren’t given that leeway. We are held on an incredibly tight leash and can practice according to community standards. Who sets these standards? The majority of physicians who have learned to change their practice styles based on consumer demand.

No physician can practice independently even if they have the 6th sense to do so because should their time come before a judge and jury, they’ll be held to the standard of care within the community.

 

Culture of Medicine

In the US the culture of mainstream medicine will continually push more interventions because customers demand it.

As physicians we don’t have the time in the exam room to offer the basic education necessary to help comprehend the antibiotic argument. Patients are paying for convenience and speed and are upset when they are met with resistance.

The average US consumer who frequents the healthcare system doesn’t have a solid grasp on limited resources, conservation, or budgeting. I can’t teach that in the exam room.

In the exam room I have a limited number of options and I will choose the path of least resistance when the going gets tough and the going has been tough for a long time for front line physicians.

 

The Cost of Medicine

It’s important to finally point out the cost of healthcare.

As we drag physicians through court systems and investigations and force them to deal with disciplinary actions by their hospital systems.

We are directly building in the higher cost of healthcare.

Consumers have made this choice. It’s not like they have to go through a formal voting process or obtain permission to sue their doctors. Anyone can sue anyone in this country. By retaining the right to sue your doctor not only are you creating a far more difficult environment for the doctor to practice in but you, as a consumer, are also paying for the many missed work-days, the extra training hours, the cost of legal counsel, and the many rules and regulations that have to be lobbied for by the AMA in order to protect physicians.

[I’m not defending the AMA. It is a turd of an organization which claims on Capitol Hill to represent all physicians in the US even though less than 20% of physicians are AMA members. But it’s not like I can stand up for myself other than blog my voice.]

As the Oregon Medical Board put it so eloquently to me: “You realize that it’s a privilege for you to practice medicine in the state of Oregon, right?” 

 

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