Trying to save money, more and more of my patients refuse to allow me to order all the tests and treatments I think they need. Then I feel as though I am practicing medicine on some frontier where modern tests and treatments are not available, making do with medical duct tape and baling wire when the best care might be medical wizardry and hospitalization.
For example, a 63-year-old male patient with no health insurance presents to my office with a story suspicious for angina — the heart pain caused by partial blockages in the arteries to the heart muscles.
Ordinarily, I would confirm my impression that he has angina with a stress treadmill (maybe $500) and check his heart function with an echocardiogram (another $500). If the treadmill was markedly abnormal, I would send him to the heart specialists for a heart catheterization (maybe $5,000) and perhaps a balloon angioplasty to open the blockages, with some stents put in to keep those opened areas from closing up again (maybe another $5,000). Then I would put him on my favorite cholesterol lowering medicine (about $80 per month) and about three other meds that would cost him another $30 bucks a month. Total bill for all this over a year: maybe $13,000.
Let’s say, however, that he does not have that kind of money to spend. Then I am in a bit of trouble. First, I will have to make this diagnosis on the strength of an educated guess. What if I were wrong and put him on pills he does not need, and gave him a diagnosis he should not have? What if I missed crucial blockages that put him at higher risk for a devastating heart attack because I have no stress test or heart cath to go on?
This leaves me in the awkward spot of having to consider which tests give us the most medically useful bang for his buck. What information is crucial for us to have for his care, instead of just helpful? Or I have to talk him into spending a little more money to get one more test, one more piece of the puzzle. Or in the case of a recent ER patient I thought was at high risk for a heart attack, who wanted to go home to avoid the cost of hospitalization, it had me looking for the one thing I could say that might convince him some things are more important than debt.
In some cases, the less expensive approach might be the approach that medical studies have said is the best one, even if we were driven to do it because there was no extra money to spend on the first patient’s heart. There is some evidence, for example, that patients with stable angina can be treated with medications and without balloons and stents. There is some evidence that old generic meds are some of the best medications out there, less expensive than their glitzy, name-brand competitors but no less effective.
In some cases, less care is better, but less care is awfully difficult to provide. It can take more time to explain why I think no test or treatment is necessary, or how new studies have come out saying the old way of doing things turns out not to be the right way. This approach may give me less reassurance I am providing the right care. It may give me more risk; malpractice suits in medicine often result when some test or procedure was not done, not because it was done.
As more patients ask me if they really need some test or treatment, no one is helping me in a comprehensive way to answer those questions. No one is putting information about the risk of one approach versus another into a nice brochure that my patient can read at his leisure, or the information at my fingertips on the computer. No one is paying me more for taking more time to spend less of a patient’s money.
The entire health care system works in many ways to support my doing more testing, more treatment and spending more of my patient’s money. When I buck that trend I feel very lonely.
Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region. He is also the interim CEO at Blue Hill Memorial Hospital.