Monday, March 27, 2017

Higher Spending by Docs May Not Buy Better Health

Just because your doctor orders more – or more high-priced – tests and procedures when you’re in the hospital doesn’t mean that you get better care, a new study suggests.

Medicare patients treated by higher-spending physicians are just as likely to be re-admitted or die within 30 days of being admitted to the hospital as patients treated by doctors who order fewer or less-expensive tests and treatment, the study revealed.

“Spending more doesn’t always mean you get better health,” senior study author Dr. Anupam Jena, of Harvard Medical School, said in a statement.

Health care spending in the United States varies widely from one region to the next, and even across hospitals within the same community, studies have shown.

However, this new analysis is believed to be the first to assess spending differences between physicians within the same hospital, and patient outcomes.

Among “hospitalists” – who treat patients while they’re in the hospital – average adjusted spending per hospitalization varied by more than 40% between the highest – and lowest-spending physicians.
The study was published online March 13 in the journal JAMA Internal Medicine.

The study authors concluded that policies targeting physicians within hospitals “may be more effective in reducing wasteful spending than policies focusing solely on hospitals.”

Hospitals began monitoring physicians spending patterns years ago using patients’ length of stay, and over the years the list of measures has expanded. Beginning in 2019, for example, Medicare will begin rewarding or penalizing physicians on the quality of cost efficiency of care they provide.

Medicare is also shifting to a payment model that rewards hospitals for value over volume of care by bundling payment for all services associated with a particular type of care, such as hip replacements.

My Take:
Eighty percent of all medical costs are for testing rather than treatment. As I frequently tell my patients, “testing never makes the patient better, but if it confirms the diagnosis and treatment, then it’s worthwhile.”

Unfortunately, the science and art of diagnosis has been lost. Diagnostic tests are supposed to be confirmatory rather than a fishing expedition. But today it is not uncommon for a patient to have a $1,800 MRI to diagnose a sprained ankle.

Hopefully all physicians hold a scale to each patient to measure the risk-benefit ratio of a test or procedure. But we should also hold a cost-benefit scale to that patient as well.

Many years ago, I ordered a comprehensive stool analysis (CSA) on a patient with life-long constipation. That $500 test showed she needed hydrochloric acid (HCl) supplementation – a $12 supplement. Although we solved her 50 year old issue was it cost effective? I think not.

Today, that same test is $750 and the supplement is now $15. But I can find the need for more HCl production during a routine office visit and should suspect it from the history. Furthermore, I would rather stimulate HCl production with zinc or some other precursor than give them a digestive aid.

I think it’s fair to run more testing early in practice when you have less clinical experience. I was taught to x-ray every new patient and that standard of practice is still taught at every chiropractic college in the nation. Over time, clinical discernment replaces some “standard testing”, especially if that test has an inherent risk, like x-ray. I sold my x-ray equipment 20 years ago and never looked back. When I need to have imaging studies on a patient, I send them to a radiologist.

The Bottom Line:
A good history and examination will narrow the testing window down to the most relevant testing that confirms a reasonable diagnosis. Otherwise, you have to throw a broad (think expensive) net blindly and hope you catch something.

Source: March 13, 2017 National Institute of Health

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