We Can Do Better

Sometimes it’s ignorance. Sometimes it’s indifference.  Sometimes it’s greed. Sometime’s it’s just a mistake.  The bottom line is that we can do better.  A new study found that in a single year:

  • More than 600,000 patients underwent a treatment they didn’t need, treatments that collectively cost an estimated $282 million.
  • More than a third of the money spent on the 47 tests or services went to unnecessary care.
  • 3 in 4 annual cervical cancer screenings were performed on women who had adequate prior screenings – at a cost of $19 million.
  • About 85 percent of the lab tests to prep healthy patients for low-risk surgery were unnecessary — squandering about $86 million.
  • Needless annual heart tests on low-risk patients consumed $40 million.

And this is only in the state of Washington!!

Wasted spending isn’t hard to find once researchers — and reporters — look for it. An analysis in Virginia identified $586 million in wasted spending in a single year. Minnesota looked at fewer treatments and found about $55 million in unnecessary spending.

This is kind of ridiculous.  We need to stop being ignorant, indifferent, greedy and realize that this stuff is inappropriate.  Mistakes can happen but the rest is on us.

The article mentions some patients who demand these tests.   I think that is valid but that is a small percentage of this problem.

What are your thoughts?

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  25 comments for “We Can Do Better

  1. Craig
    February 8, 2018 at 12:28 am

    More and more patients demands thing they have googled. Doctors are not respected. Doctors cave. I’m done. If you disagree, buh-bye. If you don’t prescribe abx, many patients just go to an urgent care to be seen for the same thing twice and drive up cost. So why even play the game? Luckily, I live in a physician shortage area, so I have too many patients. Had a patient today with a head CT 3 weeks ago that got another in the ER 2 days ago with nothing different in her Hx or presentation. Done. Finished. Jaded. Ready to quit. Next patient to piss me off is out!

  2. Pat
    February 7, 2018 at 8:04 pm

    Tell the lawyers.

  3. ckoop
    February 7, 2018 at 3:26 pm

    Excellent comments! I agree that the main drivers of over testing and over treating are patient demands (if not met then poor satisfaction scores or official complaints), increased waiting times (may lead to poor satisfaction scores), externally imposed metrics, RVU thresholds, hospital CEOs lack of knowledge regarding appropriate medical practice, greed by both hospitals (for employed physicians) and individual physicians, and finally simply poor medical practice (failure to adequately take a good history, perform an adequate examination, inability to diagnose properly-overtreatment of ear pain by using antibiotics for a red TM without purulent middle ear fluid or treating a URI as sinusitis.
    Because of the problems with hospitals and payers currently holding the upper hand (especially with hospitals CEOs or CMOs (the latter are just mouthpieces for the hospital in our current time) the time is ripe for physician unions or some other active physician organization that will adequately represent our real needs.

    • Sir Lance-a-lot
      February 7, 2018 at 6:32 pm

      There are unions, such as the Council of Interns and Residents (which also represents some attendings).
      The trick is to get your colleagues to join one with you.

  4. T Newberry
    February 7, 2018 at 3:21 pm

    If you extrapolate, this might be as much as $25 billion per year for all the states!

    If we could just eliminate that we could reduce healthcare spending from $3.2 trillion to $3.2 trillion. Oops, sorry. I rounded that. From $3,200 billion to 3,175 billion.

    That’s right. As bad as this sounds, it is a rounding error in the total healthcare economy, which grows by more than $100 billion per year.

    There is no fixing this system. It must be replaced.

  5. Steve O'
    February 7, 2018 at 2:36 pm

    Part of the race to the bottom is whether the Internet Jury concurs with your professional judgement. Or in the hospital, agreeing with the dumbest person making the ‘team decision. ‘

  6. Chris
    February 7, 2018 at 11:52 am

    The Washington Health Alliance, whose recommendations this study was partially based on, says that it is inappropriate to treat ear infections with antibiotics and that PSA screening should not be done.

    I don’t know how we as physicians ever got to the point that treating an ear infection with antibiotics was malpractice. I know that there have been some studies on methodologies of treating children with ear infection with symptomatic treatment only in the first 24-48 hours of symptoms with symptomatic treatment and then very close followup. I know of no rational physician who says that all ear infections are viral and thus antibiotic treatment is inappropriate no matter duration, injury to the TM, systemic symptoms, etc. The argument that we are somehow inducing VRE in 80 year-olds by giving 2 year-olds a few days of amoxicillin for an ear infection is insane. We are inducing drug resistance by keeping terminally-ill gomers with aspiration pneumonia alive in the icu on a ventilator and maxed out antibiotics for days and days before withdrawing care.

    I do not agree that PSA screening is inappropriate. Most of the arguments against PSA screening are utterly irrational (mostly revolving around the idiotic idea that it is better just to ignore the risk of prostate cancer entirely until it presents through symptoms of metastases) and I routinely order PSAs on men over 50. The major issue with PSA testing is that it has a high false positive rate, which is an accepted risk in a test that has an exceptionally high negative predictive value. I would categorically say that I have never diagnosed a patient with prostate cancer except through them having an elevated PSA and I think it accepted fact that DRE alone has a very low sensitivity. I find it highly unethical to substitute my judgement as to what a patient would want to have done to evaluate an elevated PSA and subsequently diagnosed prostate cancer by just not ordering the screening test in the first place.

  7. Chris
    February 7, 2018 at 11:04 am

    I always have to laugh (better than crying) when I see studies done (usually by people with MPH degree) telling doctors that we waste money ordering useless tests. They say that 85% of the pre-op tests were a waste. What about the 15% that were not? I can’t predict which patients we will reveal to have occult renal or liver failure, leukemia, lung cancer or heart disease on a pre-op workup for an elective surgery (I have found all of the above) and prevent a patient from dying on the table. Or having a knee replacement surgery when they are actually terminally ill. I bet they didn’t go into determining how much money was saved from preventing elective surgeries on terminally ill patients. Part of this study was based on tallying up the amount spent on tests that the USPHTF says are a waste of money. The problem is that organization has ZERO credibility. Among other stupid recommendations, when I was a resident physician the USPHTF handbook (which we were all given a copy of and expected to read and obey) actually said that doctors should not counsel their patients on smoking cessation because it was a waste of time. The USPHTF is focused on cost-effectiveness, not doing what is right for a patient and cost-effectiveness and preventive medicine are terms of contradiction because very few preventive medicine measures can be demonstrated to be cost effective (immunizations and screening colonoscopies in select populations are about the only ones).

  8. Sir Lance-a-lot
    February 7, 2018 at 11:03 am

    I’m the weirdo in my group who doesn’t ALWAYS get strep tests on sore throats, doesn’t ALWAYS get flu tests on fevers, doesn’t ALWAYS get X-rays on painful joints, and doesn’t ALWAYS get CTs on neck pain after MVAs, and you know what it gets me? Nothing, other than the occasional pissed off patient who “wasn’t really checked.”

    Might as well just order everything on everyone – then they feel like they’re “cared for.”

    • chris
      February 7, 2018 at 11:27 am

      I almost never use strep tests. If the patient clinically has strep (sore throat, cervical lymphadenitis, fever, pharyngeal erythema, palatal petechiae) I treat.

      My practice is shaped by my experience with a dimwitted pcp to whom I went when I was 18 years old with several days of 4+tonsils covered with pus, fever, and anorexia. I stuck a swab in my throat and told me he would call me back in 3-5 days to tell me if any treatment was indicated. I insisted he prescribe me some antibiotics, he relented and I improved in 24 hours but never went back to see him again.

      • Sir Lance-a-lot
        February 7, 2018 at 11:31 am

        Perhaps the AAFP can produce an article or “learning module” entitled “Identification of Anatidae Through Consideration of Typical Anatidaean Characteristics.”

        • Chris
          February 7, 2018 at 12:14 pm

          Yes, its actually learning physical examination and history taking, which I find sorely lacking in many colleagues (mostly younger). It seems its easier to get a CT scan rather that spend 5 minutes talking with a patient and examining them.

          A little anecdote. I got a call from the ER doctor one night to see a elderly patient. He told me she was in acute chf (his reasoning being that her BNP was elevated) and he had given her some lasix before he called me but that she was going to need to be admitted. So I came to the er to see the patient. Truth was that she had been having several days of intractable nausea, vomiting and diarrhea. She was hypotensive, tachycardic and in acute renal failure. She had poor skin turgor, dry mucous membranes. Her lung fields were clear, her cxr showed no signs of chf and she had no edema but somehow since the advent of the BNP, the elevation of this test has become the sine qua non for CHF and to hell with doing a physical exam or taking a history. Sadly that patient died a couple of hours later.

          Another anecdote: I came to see a patient in the hospital who had been admitted for chest pain. Serial cardiac markers, ekgs and a cardiology consult had been ordered on admission. In truth his upper back was hurting on one side. Somehow the ER doc thought this was an “anginal equivalent” even though he had no other symptoms to make one think that. I lifted his shirt and he had an obvious case of zoster; it was obvious nobody had done even a cursory exam The poor guy was uninsured so he probably had something like a $5,000 bill for something he should have been charged <$100 doctor charge and a prescription that would cost him like $10.

          • Yv
            February 7, 2018 at 1:29 pm

            I feel your pain. I’m EM and consider myself an astute clinician. I insist that every patient be undressed for an exam, it is an ED for God’s sake. The time it takes for me to get a pretty good history and perform a focused exam may be a bit longer than my colleagues. I’ve lost jobs as a result. May be why you are witnessing sloppy medicine. The push for throughput times and Door-to-Doc times are real metrics to which we are strictly held. Add to that the waiting room of patients constantly complaining about the wait….Hence, the patients aren’t undressed, unnecessary tests are ordered to “expedite” care and the evaluation and exam is brief. Being quick in the ED is highly admired, being meticulous is not. Doc has a choice, rush through the patients and keep your job or be more thorough, get bad Press-Ganey scores for impatient patients and lose your job. I chose the latter. It ain’t fun being unemployed.

          • Steve O'
            February 7, 2018 at 2:26 pm

            Ditto. Plantaris tear yesterday, d-dimer trivial elevation from bleeding. DVT admitted, heparin loaded.

          • CHRIS
            February 7, 2018 at 3:16 pm

            So here’s a not-so-funny personal story about that. When my physician group closed its doors the hospital hired me and I opened a primary care practice in their now empty POB on campus. At about the same time the hospital came to the staff and wanted to start using nurse practitioners in the ER because the ER doctors were too overwhelmed with sore throats, rashes and splinters to treat people with life threatening conditions. Simultaneously I had discussions with the ER Medical Director regarding their overcharging patients for simple illnesses and asking them why they didn’t triage those patients out of the ER to an urgent care clinic…LIKE MY OFFICE…instead of hiring NPs to staff the overcrowded ER. I was told that EMTALA prevents the ER from directing these patients to an urgent care clinic unless they do a “medical screening” and that if they do that they may as well just treat the patient. During this period of time I sent a patient of mine to the ER with what turned out to be an acute appendicitis and the patient walked out (bent over at a 45 degree angle at the waist) of the ER and went to another hospital after waiting 45 minutes with no attention. Fast forward a few years and now the admitting attendings are getting calls from NPs working the ER to discuss admitting people with acute CHF, sepsis, pneumonia,shock, respiratory failure, etc. I’m not sure what the MD/DO ER doc is doing if the NP’s are the ones working up this stuff. I no longer do inpatient work, and this is one of the reasons. Now after 10 years the hospital administration finally woke up to the fact that even though their provider charges are >$400 per visit, they are only getting reimbursed an average of <$50 per patient visit to the ER for these minor illness and even using a NP they are losing money hand over fist doing this and they ask my advice on how to fix this but since they never actually take my advice I have finally learned to stop offering it, it only to maintain my own sanity.

  9. Perry
    February 7, 2018 at 11:02 am

    There are a myriad of reasons why we do more, patient expectation/satisfaction, legal concerns, the concern over possibly “missing something”, tradition, need to follow guidelines or metrics, and unfortunately just plain greed.
    As patients may be finding themselves paying out of pocket for more medical care, they will probably lighten up on their expectations as their pocketbook is affected.
    Until or unless the legal situation is remedied, I don’t think much else will change from that avenue.
    As far as greed goes, the bad apples will continue doing what they do while the rest of us try to do what is reasonable.

    • R Stuart
      February 7, 2018 at 12:26 pm

      In primary care, I would put greed way down the list – almost none of this puts money in our pockets, and in fact when you consider time involved, we lose money when ordering tests.

      • Chris
        February 7, 2018 at 12:45 pm

        I might make a few bucks on EKG and INR, strep and flu tests on commercial insurance patients. Mostly its a matter of avoiding losing money on these tests. And since I am an RHC I don’t get paid anything for these for a medicaid or medicare patient which is maybe 60%+ of my patients.

      • Chris
        February 7, 2018 at 12:58 pm

        Greed on the part of the hospitals maybe. I was COS for my hospital a few years back and as part of that went to the hospital systems annual meeting. During one the the discussions the hospital system CEO said to us that our hospital system had an unusually high rate of attempting outpatient treatment for people presenting to the ER (without any evidence that we had a bunch of deaths or otherwise bad outcomes for these patients) and that this needed to be fixed. I was puzzled because I was trained to hospitalize only patients who really needed hospitalization

        • Perry
          February 7, 2018 at 3:42 pm

          In reply to your latest post up there, hospitals are stupid and greedy. They are only looking out to increase market share and the dollars they can earn. My wife’s hospital did not renew the contract for the ER docs that had been there for almost 40 years, probably did not want to pay what they were worth. Now they have a group made up of locums, PAs and NPs who may be good in urgent care but not a major trauma center. As a result, the hospital’s reputation is tanking. Oh yeah, and there were some COI type relationships between some of the hospital board members and the head honchos of the new group.
          The old CEO that made this blunder left with a 3 million dollar parachute.

      • Perry
        February 7, 2018 at 1:53 pm

        I would agree with that. It always burns the hell out of me when they talk about how bad fee for service is because those greedy doctors order more tests.

        • R Stuart
          February 8, 2018 at 7:41 am

          And nobody has bought into that line more than the idiots at the AAFP.

  10. Thomas Guastavino
    February 7, 2018 at 7:19 am

    Three reasons: Malpractice layers, patient satisfaction scores and boneheaded “quality” metrics. Used to be just the first but then the boneheads added the other two.

    • Chris
      February 7, 2018 at 12:40 pm

      Agreed. Our hospital has this stupid policy that you get an A1C drawn automatically if you are admitted and have a diagnosis of diabetes and have not had one in the past 6 mos. I asked why this was and was told it was due to a quality metric because our hospital wants to maintain a designation as a center of excellence for diabetes or some such thing. I told them that I personally knew of people who had an A1C drawn due to this policy who had just had one done at an outside lab, had just recently had a change to their diabetic regimen, had recently received treatment with steroids, had just recently had a massive blood loss or a transfusion, and on and on and that the majority of this routine testing was a complete waste of money. It fell on deaf ears.

  11. Dr Bonz
    February 7, 2018 at 6:47 am

    Until hospital systems stop requiring me to order a specific set of preoperative tests in order to meet their ridiculous “quality” measures and until plaintiffs attorney’s decide to stop filing lawsuits for NOT obtaining what they feel is “appropriate” preoperative medical clearance and testing, then I feel forced to continue to order the testing that is being deemed unnecessary.

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