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Health Care Fail?
Doctors Admit Unnecessary Tests and Treatments

One driver of runaway health care spending is over-treatment, a problem widely acknowledged by medical professionals. So why hasn’t anything been done to counteract the trend? Perhaps it’s easier to diagnose in others than oneself. A new poll of doctors found that 3 out of 4 MDs believe their colleagues order unnecessary tests or perform unnecessary treatment. Kaiser Health News breaks down the numbers:

In the survey, 47 percent of doctors said one patient a week requests something unnecessary. While most doctors believe they are most responsible for interceding, 48 percent said that when facing an insistent patient, they advise against it but still order the test. Another 5 percent said they just order the test […]

Not surprisingly, few of the doctors agree with health policy analysts who believe that the financial rewards that come from extra procedures are a major reason why they are ordered. Only 5 percent of physicians said they are influenced by the presence of new technology in their offices. Just 5 percent believe the fee-for-service-system of payment, where physicians are paid for each thing they do rather than a lump sum for keeping a patient healthy, plays a role.

It’s unsurprising that doctors would claim that concern for patients trumps financial benefit. But both patients and doctors are working within a system with perverse incentives. Patients with comprehensive insurance can’t easily discern the real costs of their treatments. Doctors are encouraged to over-treat because they earn a fee for each discrete service, and have to make expensive new technologies profitable.

Demanding patients, who are often insensitive to costs, interacting with trigger-happy doctors, makes for a fiscal disaster that none of the parties are fully responsible for. Changing the structure from the roots is crucial to making any significant progress to an affordable system.

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  • MarkE

    We already know how to solve this problem with a market based solution where patients and doctors feel the cost of procedures and meds as they consume and prescribe them. Patients who don’t have the resources to be I this market have to be in subsidized HMO type system, but they would still benefit from the rationalized pricing and consumption from the market

    • Andrew Allison

      We could help doctors resist patients who think they know better than their doctors by requiring that they, rather than their insurance companies, pay for care which the doctor deems unnecessary. Patient demand for clearly unnecessary procedures is quite different from the need for doctors to protect themselves from malpractice liability.

  • Perry R Branson

    You are missing a major point here. In our current litigious environment, a Doctor who does not order a test which might have diagnosed a serious condition will be sued and will lose. The Doctor who orders the test, even if unnecessary 999 out 1000, will not be sued. I order many tests that are almost certainly unnecessary and I am on salary so have no financial incentive to do any tests; our malpractice lottery system any be the most perverse incentive of all.

    • Andrew Allison

      Did you miss “In the survey, 47 percent of doctors said one patient a week requests
      something unnecessary. While most doctors believe they are most
      responsible for interceding, 48 percent said that
      when facing an insistent patient, they advise against it but still
      order the test. Another 5 percent said they just order the test.”? This post is not about malpractice CYA (dreadful though that problem is), it’s about acceding to patient requests.The latter, with respect to unnecessary antibiotics, is a significant contributor not just to health costs but the drug-resistant disease problem.

      • Dinobot

        I hear what you say, but it isn’t that simple, Andrew. Besides the malpractice CYA and litigation for medical negligence which is bad, a hostile media, opportunistic activists and ambitious politicians would make things worse. Believe me when I say to you that if given the choice, most doctors will refuse to order unnecessary diagnostic procedures, medications or even hospital stay if the medically determine the patient won’t need it but perverse incentives from hospitals, lawmakers, media and activists makes it so hard to resist for doctors to not order those unnecessary tests and medications in order to stay in practice.

        • Andrew Allison

          There are two issues here: doctors ordering unnecessary diagnostic procedures, medications or even hospital stay if they medically determine the patient won’t need it because of the perverse incentives to which you refer; and ordering them because the patient wants them. We’re discussing the latter. One solution might be for insurance companies to require the physician to certify that the care is necessary, in other words, let the patient pay in full for things which the doctor advises against.

          • Dinobot

            I don’t like the government or insurance party require a physician to certify that the care is necessary for several reasons, it removes autonomy on the decision making of the physician involved and second, perverse incentives to deny those who might really benefit from the additional care, tests or medicines.
            Let the patient pay in full for things that the doctor advises against which I agree whole heartedly. Heck, show prices of medications, diagnostic tests, radiological tests and hospital stay from every provider and every hospital and let the patient compare prices. Let us see how patients react if they found out that they have to pay 120 dollars every time they do a lab draw for CBC or CMP or an X-ray cost 300 each film and read . That would sure decrease the frequent fliers and hospital shoppers .

          • Andrew Allison

            I don’t see how checking a box that says the care wasn’t deemed necessary reduces autonomy, or what the incentive is to deny needed treatment (surely the malpractice, et. al threats prevent that). In fact, it appears to me that forcing physicians to acknowledge that the treatment was unnecessary might stiffen the spines of the 53% who order the treatment anyway.
            How would you propose making an insured patient to pay the full price for treatment which the physician deems unneeded?

          • Dinobot

            The problem is that almost all the insured and uninsured does not know how much x test and y medication really cost before and during hospital stay and we haven’t discuss the cost of the hospital bed and the length of stay which many patients tend to ignore until they see their hospital bills. As long as the American people remains ignorant of the cost of the actual service, they will be set in their ways thinking that their insurance companies will handle everything
            Have the patient discuss the problem with the Nurse Case manager of the Unit he or she is on. Since the latter is verse with insurance issues, she can educate the patient on the cost of the unneeded treatment that her insurance refuse to cover. If the patient insist, the hospital will charge her for the treatment.

          • Andrew Allison

            I agree completely, except for the last paragraph. What we’re talking about is primary care doctors ordering unnecessary tests, procedures and drugs at the insistence of the patient, not in-hospital treatment options. I suspect that hospitals are much less likely to receive, or accede to, patient demands for unnecessary treatment.

  • Maynerd

    The WRM blogger is only half right. Financial incentives for doctors who own their own equipment, e.g. Orthopedic surgeons with an MRI, clearly over utilize and profit from their self referral.

    However, the vast majority of docs don’t own their own imaging equipment or labs. Demanding patients are a small but real problem. A physician is never rewarded for saying no. First of all hospitals are terrified of poor patient satisfaction results (HCAPS). It directly affects their reimbursement. Secondly, angry patients tend to sue and our medical legal system is a disgrace. Thirdly, who wants to argue with an angry patient when you are already behind schedule? Fourth and final point, mid levels (PA’s & nurse practitioners) over test like crazy. Saving money by replacing docs with mid levels drives up ancillary testing costs.

    • Andrew Allison

      Evidence please.

  • Jacksonian_Libertarian

    “Changing the structure from the roots is crucial to making any significant progress to an affordable system.”

    Yes! Now you’re getting it. Only free markets have been shown to produce continuous improvements in Quality, Service, and Price. This is because of the “Feedback of Competition” and threat of survival force businesses to change for the better. The customer (Patient) must bear all or most of the cost of their medical care or they won’t shop or take responsibility for their health.

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