In my last column, I addressed the contribution of unrealistic patient expectations to unsustainable healthcare costs. I postulated that the competing societal goals of preserving freedom of choice while providing healthcare for all will produce a futile tug-of-war. I further warned that leaving the solutions to politicians and government administrators will inevitably lead to myopic reforms that threaten the doctor-patient relationship and fail to consistently incentivize good care. In this month’s column, I’d like to take a closer look at some the specific sociological drivers that have created self-induced barriers to implementing high-quality and cost-effective healthcare in this country.
The “Money-Back Guarantee”
There is perhaps nothing more American than the money-back guarantee. We have grown dangerously accustomed to risk-free “purchases.” Patients have been driven madly into the belief that medical decisions should also come with a guarantee. As clinicians, we are expected—for that matter demanded—to “rule out” every possible malady for every possible presentation. MI’s, CVA’s, tumors, and the like all must be ruled out because there remains a possibility, no matter how slim, that they may exist. This is expected. If you do not deliver on this expectation, patients will leave unhappy, consider your care sub-par, and sue you if you’re wrong. Just think of how many unnecessary admissions for chest pain you’ve done in the last year. Society has not given you permission to use your best judgment and will punish you for it, no less. You “gambled” on a decision and you were wrong. You WILL pay.
I had a mother bring in her 13-year-old daughter the other day with a headache for six hours. No effort was made to treat the headache with OTC pain relievers. I took a thorough history, performed a thorough exam, and looked for any red flags that this could represent a dangerous headache (far-fetched to begin with). Her headache was so benign and mild that I couldn’t even call it a tension headache with a straight face. When asked what was causing her headache, I simply had to reply, “I don’t know. People just get headaches sometimes.” This of course drew a puzzled and angry look from her mother. “What do you mean you don’t know? That’s not a diagnosis! Can you guarantee me she doesn’t have a tumor or bleeding? She needs an MRI!”
“He Who Dies With the Most ‘Tests’ Wins”
While perceived quality and risk aversion understandably drive utilization, less apparent and more stunning is the role peer pressure. Nowhere does this impact unnecessary testing more than with MRI’s for simple knee pain. This bizarrely becomes apparent at every party, social hall, or assisted-living dining room. A veritable horse race ensues as people jockey for a leg up on the number of procedures and scans they have had. Low utilizers are considered ignorant or weak. “You tell your doctor you need an MRI” echoes across the room. While there is zero evidence supporting MRIs in the evaluation of simple, a traumatic knee pain of less than six weeks’ duration, social pressures have become major market drivers. Yes, that’s right, people use access to healthcare services as a social currency, and more is just simply better.
Who Will Pay for Reforming Expectations
According to the Kaiser Commission on Medicaid and the Uninsured, an additional $48 billion per year over current healthcare expenditures would be required to insure all Americans. That’s less than 7% of the $700 billion wasted annually on unproven care. The expectation of healthcare reform in large part demands that the physicians tell their patients that they don’t need these unproven tests and procedures. Unfortunately, if I had to talk every intervention seeker, scan seeker, and guarantee seeker out of all of their expectations, it would take me 10 times the amount time per encounter. The vast majority of hard-working, non-proceduralist physicians I know can barely make a respectable living without acquiescing to wild patient expectations. It will be a hard sell to get them to spend more time for less pay.
It is long overdue for Americans to take a hard look in the mirror and recognize the patients’ role in driving up healthcare costs. Supporting measures that ensure more appropriate utilization by empowering and paying for a physician-led re-education without the expectation of a guarantee is the only solution. All sales final … no refunds, returns, or exchanges.
Lee A. Resnick, MD
Editor-in-Chief
JUCM, The Journal of Urgent Care Medicine
