Yusuke Tsugawa, MD, MPH, PhD, of Harvard University’s T.H. Chan School of Public Health, and colleagues published a study that looked at healthcare spending of hospitalist physicians and patient outcomes (30-day mortality and readmission rates). The higher-spending physicians did not produce better outcomes; or, looking at it another way, “going economy” did not result in worse outcomes.
Many years ago, I proposed that there should be a running tab on every patient chart so that the treating physicians could see the bill they were racking up for the patient. I can hear someone now saying, “That is not what they have to pay.” I am aware, but I firmly believe there is a lack of awareness by all of us about the cost of services we order and provide. Even taking your car into the shop requires that they provide a bid and then let you decide if you wish to go forward with all, some, or none of the suggested services. Healthcare has no such checkpoints.
Obviously, some scenarios do not lend themselves to price haggling; an emergency requires intervention. But is it really necessary to investigate for every zebra? For example, I saw a new patient this week—68 years old, presenting with abdominal pain, 40-pound weight loss in a month, history of alcohol abuse, and a CT scan showing a large mass in the pancreas and diffuse liver metastases. She was admitted for evaluation and liver biopsy to confirm the diagnosis of pancreatic cancer with liver metastases. The records they sent to me were over 100 pages, despite the fact that she was only in the hospital for 4 days. She had undergone multiple extraneous tests, yet when she came to the office, her family said that no one had even told them her diagnosis. In truth, the oncologist had last noted that a discussion would wait until the return of biopsy results. Really? You don’t even have an educated guess what this patient might have? She was discharged with no discussion. There was never even a preliminary talk with the patient, but they sure racked up an impressive array of diagnostics. If that oncologist had spent 5 minutes with the patient, he or she would have learned that she was extremely pragmatic but also very opinionated about not giving up her lifestyle for chemotherapy. (I did convince her to at least hear about palliative treatment.) My point being, sometimes we are so focused on testing that we forget to look at—and talk to—the patient. A workup could potentially be refined with a discussion. Or at the very least, take a breath before ordering layer upon layer of imaging studies, none of which actually change the treatment plan.
Here is a different example: the yearly “executive physical.” I live in an area with a highly health-conscious population. I cannot count the times I’ve heard perfectly healthy people brag about going for their annual checkup at some premier institution because “the company pays for it.” They get a full complement of tests that makes them feel that something has been done to prevent a dire illness. This behavior feeds the belief that spending money equals better healthcare. I bet that same company makes me spend many precious minutes on the phone to get authorization for a follow-up CT scan or to use a granulocyte colony-stimulating factor for an actual sick patient.
When are we going to stop equating spending more with better care? In Tsugawa’s study, he concludes that spending varies across physicians, not hospitals. Continuing to hold institutions to specific outcomes may never result in spending control. We need to educate individual physicians on cost-effectiveness in treatment planning. Simply being cognizant of what we order and what we plan to do with the information is a good first step. Don’t order everything on every patient by routine, do it with thought. As they say, “Why pay more?”