Cost Controls and Health Care Education

by: Dan Summers

“The art of medicine consists of amusing the patient while nature cures the disease.” — Voltaire

While reading Jason’s predictions about the health care reform bill, I was struck by one of the comments. Commenter A. R. Yngve wrote,

My dad was a physician (the “general practitioner” sort) in Sweden.

Toward the end of his life, he collaborated on a thick booklet titled “Self-Care” which was sent out for free to I don’t know how many people in his administrative region (Sweden has both regional and municipal administrative regions for public health care).

The purpose of “Self-Care” was prevention: to educate the public about various common afflictions and infections, how to identify symptoms on your own, and how to prevent ill health, infection and injury.

This got me thinking. As a purely speculative exercise, I wonder how and if a similar program might work in the United States.

The simple truth is, at least in the case of pediatrics (my specialty), patients are frequently brought in for illnesses that do not require evaluation by a medical provider. While it’s nice for parents to be reassured that their children are basically well when they’re going through one of childhood’s myriad contagious illnesses, from a cost-benefit perspective many of those visits are hard to justify. I imagine that this is true for other health care providers, not only in primary care settings, but also in emergency departments and urgent care clinics.The most common example is the viral upper respiratory infection, or cold. For the overwhelming majority of patients who present with this complaint, there is little that can be done other than supportive care. In other words, I can’t fix a cough, runny nose or chest congestion. To concerned or exhausted parents this can be frustrating news, particularly as over-the-counter cough and cold medications aren’t recommended for young children. And I share their frustration that there is no meaningful intervention to be offered other than reassurance. But the reality is that most of those patients could get by without my seeing them, and without incurring the costs of the office visit.

I laud the President and Congress for trying to correct many of the worst problems regarding health care coverage (I am generally supportive of the current health care legislation), but I also agree that there needs to be more attention paid to issues of cost containment. It is great to increase access to health care for those who need it, but over-utilization is a very real problem. One step in the right direction would be to give patients and parents more information about the kinds of things that could safely and appropriately be monitored at home, and what really calls for a trip to see the doctor.

What might this look like?

I would suggest a series of easy-to-understand books for distribution at routine well child visits and physical exams, starting at six months of age and continuing through adulthood. (Infants under six months should generally be evaluated when they are ill, due to the higher risk of complications from even common illnesses.) It would make sense to distribute the materials I suggest at these visits, because they’re both a point at which patients are expected to show up at a specific time in their lives (and thus materials can be tailored to the right age) and parents expect to get information about health maintenance.

Topics for children should include upper respiratory tract infections, uncomplicated fevers, viral gastroenteritis (aka “stomach flu”), and some common rashes, and I’m sure any decent internist could draw up a similar list for adult patients. They should be clearly illustrated, and have useful information about symptomatic management at home. And they should help parents determine what signs (eg. lethargy, dehydration, increased work of breathing) are indications that their children really should be seen. One useful tip – if your child is well enough to merrily destroy my exam room during his visit, he’s probably well enough to stay home.

Ideally, multi-media resources (web pages, DVDs) would also be available to help with symptoms that are hard to describe verbally. For example, it can be difficult to differentiate between chest congestion (which doesn’t typically need to be evaluated) and wheezing (which does). Audio of the different sounds could help parents feel more confident in their ability to triage their own kids’ needs, and keep them from the inconvenience and cost of schlepping them in for unnecessary care.

If I’m going to create a wish list, I may as well also include information about over-testing and over-treating. There is a pervasive, commonly-encountered belief among patients (and, frankly, too many doctors) that there is some kind of value in ordering tests “just in case.” Testing in the absence of a particular clinical question to be answered generally yields useless information, or worse.

Every test ordered increases the risk of an erroneous result, which will then require its own round of follow-up testing to rule out some associated disorder. X-rays and CT scans confer the additional risk of radiation exposure. And that’s to say nothing of the monetary cost. If more patients understood that they were not being short-changed by a doctor who declined to order tests for their own sake, I am confident it would lead to a decline in the costs of health care overall.

In a similar vein, nobody is served well when prescriptions are doled out in attempts to placate demanding patients. I will readily admit that most of the onus for this problem falls on providers. It is much easier to scribble out a prescription for Zithromax than to explain to a disgruntled patient that her symptoms are viral, and will simply resolve with time. Doing so is wrong, regardless.

However, if more patients understood the natural progression of illness and some common myths were debunked (green nasal discharge = sinus infection, for one) it would take some of the pressure off, and might prevent a few repeat visits when the cough hasn’t gotten better in two days. After all, those “frequent flier” visits add up over time, and we all end up sharing in the cost.

I hasten to repeat that all of this is purely speculative on my part. These ideas are based entirely on my observations as a pediatrician after having worked both in large metropolitan medical centers and small rural hospitals. I have no data to support that a program of patient education will effect a reduction in health care costs. However, I can state with confidence that over-utilization of health care resources is a real problem, and proper patient education is one common sense approach to the problem.

In order for this to be effective, it would require a significant degree of buy-in on the part of patients and their families. As sure as the sun rises, any effort on the part of the Obama administration to increase patient education about proper utilization of resources will be met with criticism by some that this is an attempt by the government to deprive families of access to needed services, to ration care a la those infamous “death panel” assertions.

On an individual level, no matter how comprehensive and well-written educational materials may be, particularly anxious patients and parents will still opt for office visits (or, worse, trips to the emergency department) for common, benign ailments. And alarmist or venal providers will still recommend patients be seen for minor complaints.

It is that last concern that I think makes a program of this kind unlikely to ever become a reality. To put it bluntly, I have a hard time believing that the American Medical Association (of which I am not a member) would ever let this happen. Fewer patient visits mean lower income for doctors, and this kind of “bread and butter” visit shores up a lot of physician incomes (including mine). The AMA is about nothing so much as protecting physician pay, and any threat to it would be met with vigorous opposition.

If we are serious about controlling health care costs, we have to take an honest look at what we are spending our money on. A truly discriminating analysis cannot fail to uncover a great deal of unnecessary care, starting with visits that never had to happen in the first place. If a program of public education about how to avoid needless trips to the doctor’s office can lower costs for everyone, it’s a program I would gladly support, even if few of my fellow physicians were to do so.

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18 thoughts on “Cost Controls and Health Care Education

  1. Dan, wonderful post. Your point about not just the initial costs, but then the follow-on costs of needless tests seems very clear and consequential, at least to this lay person. I realize that the singular of anecdote is not data, so we have to take your view on the matter with a grain of… something…but I have long hoped for an opportunity to ask a physician this question: Many people suggest in the course of policy debates that the major driving force behind the epidemic(?) of over-testing that afflicts medicine right now is the overwhelming fear of baseless lawsuit. Is that your experience and if so, do you support significant tort reform? (I understand completely if you would prefer not to dip your toes in those waters in a public forum.)

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  2. Back when I was a kid, or perhaps I should say even when I was a kid, our family doctor would explain to me why he was not going to prescribe medications he deemed unnecessary, in anticipation of the unfortunate expectation held by many patients that “if you go to a doctor, you should leave with a prescription.” That was fine with me.

    My daughter’s pediatrician’s office screens cases by phone, and offers an after-hours dial-a-nurse service, avoiding in-office visits for minor matters. I suspect that works pretty well at reducing the number of unnecessary office visits, and probably prevents more than a few ER visits that might otherwise occur outside of office hours.

    I suspect that distributing materials to patients would be a double-edged sword – some patients would read and consider the materials as intended, while others would become paranoid that each new symptom reflected a dread disease or worst case scenario. Also, for most households, offering the information, video and audio through an easy-to-find, well-organized website would probably work better than a mad scramble to find the DVD to try to determine if the baby’s midnight chest noises are congestion or wheezing. There already is a lot of information online, but it’s not well-vetted, well-organized, or necessarily clearly written or illustrated.

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  3. I should add one more thing: Some of my “I’m sorry to bother you, but…” calls to my daughter’s pediatrician, followed by unnecessary visits for a note, were necessitated by her preschool’s infectious disease policy – if they spotted a rash, or if a child had a fever over a specific temperature point, they wanted a doctor’s note before the child returned to school.

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    • This.

      I’ve little doubt that there have been one or two occasions where my wife and I unnecessarily panicked and brought our daughter to see the pediatrician, although I think outside factors (ie, difficulty taking a full day off work combined with the fact that our pediatrician educated us well from the moment of her maternity ward visit that the best thing to do in most instances is nothing) ensure that we typically err on the side of not going to the doctor . But far more often has been the situation where our daughter gets sent home from day care with some trivial condition and won’t let her back until they’ve got some sort of doctor’s note.

      Also – add me to the chorus of voices shouting “great post.” Lots of useful info in here.

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  4. Several scattershot points:

    –In Voltaire’s day, his claim was well-founded. Given the state of medical science back then, most patients would have been better off with a hot bath, a fresh change of clothes, and a wholesome meal, rather than with a trip to a doctor. Failing that, one of the few truly useful drugs the doctors had was opium, which neatly fits Voltaire’s prescription (to “amuse” the patient).

    –I suspect that there’s a strong generational difference in attitudes between, say, my own generation and those just a bit older. I take it for granted that there is an enormous and authoritative compendium of medical information online, and whenever I have the slightest question about my health, that’s where I go first. Seeing a doctor would mostly be a waste of time and money. Likewise I research any new prescription or diagnosis. This is the only body I’m ever going to get — if anything is important for me to understand, surely it’s this.

    –By contrast, I’ve seen people in my parents’ generation on dozens of prescriptions whose names and purposes they don’t even remember. One individual was on daily Ambien for many years — a treatment plan that nearly ruined her memory. It’s also one that she might have known to mistrust if she’d looked at the Ambien Wikipedia article. Another individual had been repeatedly prescribed the same narcotic painkiller by several different doctors in succession, and she was obediently taking many times the recommended maximum dose. No wonder they thought she had senile dementia.

    It wasn’t so long ago that no one ever questioned their doctors. Now even ordinary people, with no great level of education or native intellect, have all the tools they need at least to ask helpful questions and avoid important mistakes.

    –I read a lot about doctors’ reluctance to prescribe painkillers for fear that they will be suspected of catering to the recreational market. There’s no doubt some truth to these stories, at least for some people. But there are also clearly cases of overmedication, and judging by the experience of my extended family, these are very common too.

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    • When I go to the doctor I specifically ask that they not give me anti-biotics for non-bacterial infections. Anti-biotic resistance worries me as I am allergic to one of the new family of anti-biotics. If the regular ones stop working I could be in serious trouble.

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    • “Another individual had been repeatedly prescribed the same narcotic painkiller by several different doctors in succession, and she was obediently taking many times the recommended maximum dose. No wonder they thought she had senile dementia.”

      As an immigrant from the UK, this is what particularly stuns me about the US: the total lack of true primary care. In the UK, all treatment of a patient is coordinated (and in a sense paid for) by the patient’s general practitioner. All referrals to specialists and drugs prescribed by them go through the GP. Not only does this save the unnecessary expenditures incurred when patients go to their heart specialist with indigestion, it also prevents this kind of positively harmful overtreatment.

      What puzzles me is why most insurers, with the odd exception like Kaiser that run their own hospitals, don’t insist on this. The closest my supposedly-managed health plan gets is to force me to make a 5 minute phone-call to my primary care physician if I want to go somewhere else – there’s no coordination or review of treatement at all.

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  5. Great post, Dr. Summers. We have BCBS’s high deductible insurance in ME, and have actually gotten this type of information from the insurance company after filing some claims — a child with a prescription for an asthma and allergy meds resulted in a great little booklet about living with asthma.

    I don’t know if the insurance company knew an informed client would limit their costs or if it was testing the notion, since other claims, including MRI’s for chronic back problems and Migraine did not trigger a pamphlet in the mail.

    But I also agree with Aaron’s comment — sometimes, that visit is necessary to resume life after an illness.

    A good public education campaign might help bend the cost curve.

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    • No, they’re trying to make money selling ads alongside this kind of information.

      (Sorry – I have some experience working with health information sources for the Internet Public Library. We’re told to go to the NIH Medline first).

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  6. I work in one of those heavily unionized industries that provides great health plans (but still manages to pay terribly). One of their cost-cutting measures is a 24 hour health advice hotline–someone you call and ask “should I bother going into the doctor for this?” It’s a great way to cut down on unnecessary visits.

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  7. Couple of things. First, there is evidence that more utilization of primary care docs rather than going straight to specialists does reduce total spending (see Simon above who has experienced more primary care). Next, most of our spending is not on office visits. 80% of our spending is on 20% of the population. It is the big ticket items that are killing us and chronic care. In that vein, you are correct to go after testing as a primary cause of increased costs. We do way too many just in case tests.

    We also do way too many tests that increase someone’s income. Too many MRIs are owned directly or indirectly by docs who benefit from ordering them. Beyond the financial incentives, there is just practice variation. Many of us were trained to be complete and order that extra test. We need to know our data better and trust it. Lastly, it would probably help to have malpractice reform on this issue. Anyone following guidelines should not be subject to suit. Will patient education help in this arena? Maybe, but I am dubious. In blogland everyone is bright and computer literate. In the real world, the majority of my patients (I have been keeping track) who have had a heart valve replaced cannot tell me which one it was. It would take a huge cultural change to achieve some of what you suggest. We should still try, but our big cost savings are not so much in fewer primary care visits, but in reduced procedures and tests.

    Steve

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  8. A couple of perhaps ancillary points, in relation to Mark, Jason, and zic’s comments

    Beyond schools, workplaces and gyms can require a doctors notes for various issues and it’s all defensive but nonetheless is part of a culture that says it’s better to be safe than sorry, which is prudent but expensive. I do think there’s an element of responsibility in checking in with your doctor but I think the better solution is to widen the array of medical professionals who are qualified to make certain assessments and judgements.

    Second, I don’t disapprove of zic’s suggestion of (still more) public health campaigns and think there’s something to Jason’s anecdote about a shift towards more self-diagnosis and patient involvement in care. That said, the thing that enables both to be successful, is education. At the risk of a thread jack, this is one of the problems I see with looking at problems so narrowly.

    We know that illiteracy is a deterrent to seeking medical care, even when its available and hampers the ability of patients to follow a particular regimen. So our problems with public education end up acting as a drag on the efficiencies of our health care/insurance reform efforts and to no small degree vice versa.

    Dan, this is an informative and interesting post, thanks for sharing it.

    I just want to emphasize that health care education, indeed health care is not so inseparable from education at large and to the extent that we’re talking about public health campaigns and practices that rely upon the functional literacy and cognitive abilities of “the people,” we should remember that not everyone can access such seemingly basic information.

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  9. Just a few brief follow-up thoughts. Sorry I’m so late in posting replies — Wednesday is typically my day away from the computer.

    It’s hard to say to what degree defensive medicine contributes to unnecessary testing. If you want my personal sense, I would say “a lot,” but that’s only my impression. There’s always a lurking fear of missing that crucial diagnosis, which is then compounded by the fear of legal repercussion.

    Jason, I would concur that Voltaire’s statement was more true when he said it than today. But it’s still remarkably apt in a lot of situations.

    And there are a great many Web resources, some better than others. However, finding concise, accurate, helpful information can sometimes be very difficult. It can be thus difficult to know what to trust. Materials that bear the imprimatur of, for example, the AAP and the endorsement of one’s own doctor would presumably be preferable. And, of course, there need to be clear caveats that concerned parents should always, always be free to contact their providers if they are worried.

    Thanks for all the positive feedback, everyone. It’s always a pleasure to contribute here.

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  10. Here in British Columbia we’ve got a similar thing called the BC Health Guide. It’s a good four hundred pages of things that could go wrong with you, how to prevent them, how to treat them, and how to tell when you should go to the doctor. (It’s even got a whole section on how “making wise health care decisions”). Anyone can get one for free, or call the 24-hour “NurseLine” for advice. From what I can find, the whole thing costs the government 35 million bucks a year, which is something like 0.2% of provincial health-care spending. I imagine it saves us a whole lot more.

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  11. We know that illiteracy is a deterrent to seeking medical care, even when its available and hampers the ability of patients to follow a particular regimen. So our problems with public education end up acting as a drag on the efficiencies of our health care/insurance reform efforts and to no small degree vice versa.

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