I case you didn't hear the news: the American Healthcare system is in financial crisis. One of the biggest culprits indicted in this crises is "unnecessary care," with estimates ranging from $500-$650 Billion (total spending estimate is $2.6 Trillion) going toward things labelled "unnecessary."  Personally, I think this is an underestimate, as it doesn't take into account the some big-ticket items:

  • Brand name drugs given when generics would do
  • Antibiotics given for viral infections (and the additional cost due to reactions and resistance)
  • Unproven costly care considered "standard of care" (PSA testing, robotic surgery, coronary stents)
  • The unnecessarily high price of drugs.

One of the main reasons I am an advocate of EMR is to measure and analyze care, eliminating that which is wasteful, futile, or even harmful.  The biggest burden on our system is not the fact that we have a hyper-complex payment system that hides the true cost of care.  The biggest burden is the wasteful care that this system agrees to pay for.  In fact, I suspect that the main reason our system has become hyper-complex and covert in its spending is to hide this waste from prying eyes.

It sounds easy.  Just eliminate costly unnecessary care and save the system.  While you are at it, why not bring world peace, eliminate poverty, and make a detergent that cleans, softens, and deodorizes all at once?

Yes, the problem is daunting, but the only way we can get out of the financial vortex we are in is to cut the cost.  Between the two, I favor eliminating unnecessary care over that which is necessary.  I suspect most of my readers share that emotion.  So, like peace and poverty, we need to take a bunch of smaller steps on the way to solving the problem.

But hold on, campers, I am going to pour a little water on your campfire before we all start singing Kum-By-Ya.  I don't think all unnecessary care is bad.  Yes, you read me right, I think that sometimes it is a good thing to waste money.  I've personally given "unnecessary care" several times over the past few weeks.

One time I did it was when I sent a man to hospice.  Hospice itself saves a tremendous amount of money, keeping the cost of end-of-life care under control while giving the patients maximum comfort.  But typically, you don't give drugs to prevent long-term problems to patients with a short-term life expectancy.  This man has been my patient for a very long time, and has been on the blood thinner Coumadin for the entire time I've cared for him.  He's always been very aware of his lab results and the need to keep his blood thinned to just the right levels.  He's been faithful in his taking of his medication and going for his monthly lab test.  To him, the Coumadin is at the center of his healthcare universe.  So when I sent him to hospice, I didn't have the heart to suggest stopping the blood thinner.  It was always part of his self-care.  It was always a way in which he exerted control over his medical problems.  I may be wrong, but stopping the medication would probably leave a gaping hole in his life when I was trying to make him the most comfortable.  I just couldn't do that to him.

I've had other elderly patients of the same cloth.  They don't resent the need for taking medications; they structure their days around these medications.  I have to give a very convincing argument to them when suggesting that any of these medications be stopped.  I do my best to minimize the length of the list, but I don't fight too hard.

Finally, there are the unnecessary or unproven tests.  I now routinely discuss the pros and cons of PSA testing, mammography, and Pap smears with patients.  The older a person gets, the less benefit these tests yield.  But even when I think these tests are not needed, I do give the patients the option to get them done.  Most people are relieved when I get them off of those hooks, but some are uncomfortable.  Some people find comfort in doing something rather than leaving things to fate, God, or whatever.  I do my best to dissuade and educate them, but in the end, the choice is theirs.

I don't want to suggest that I do this to most of my patients.  I routinely look at medication lists and remove whatever is unnecessary.  I am a minimalist when it comes to ordering labs, consults, or tests - only getting those I truly believe are helpful.  Most of my patients appreciate this fact, and would gladly live with as little time spent devoted to medical care as possible.  I am probably more aggressive than most in this regard.  But it is dangerous to become too rigid in our view of medicine.  Medical care is not done via mathematical formula or actuarial table, it is done face-to-face between patient and provider.  The care is based on science, but the application of the science is done by humans on other humans.

So what's the point?  The point is that care is always, in the end, personal.  I don't think we should be spending money on procedures, drugs, or hospitalizations that are not needed.  I do, however, worry that the push toward evidence-based care will start in the wrong place.  The additional cost I add to care is quickly outspent by a single hospital stay, unnecessary surgery, or even ER visit.   Those with the most money to lose in this game of cutting cost will fight the most to keep their ground.  Da Vinci surgical company undoubtedly has scads of lobbyists pushing for coverage of their procedures.  Drug companies will fight to keep the cost of their medications as high as possible.  So who will fight for my patients?  Who will fight to keep my little old man on coumadin when it's not needed?

We must cut the cost of care, but beware of what care is cut.  Cut the big-ticket items that drive up cost.  Cut the unnecessary MRI scans, cardiac caths, and the improper use of antibiotics.  Pay only for screening tests that really prevent disease, not just ones that have been hyped by the media.  But let me care for my patients.  After all, the system is about them.

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