Do everything you can, doctor

During a conversation last night with a Scottish friend, it came up that he cannot recall ever having had a blood test.

This may be the primary argument against preventative medicine saving money. Yes, you save a little when you catch conditions early. But think how much money you save by never giving healthy young people tons of blood tests and other largely unnecessary diagnostic procedures.

And how much good do the broad-spectrum general blood tests do people our age? I've had conditions caught very early by blood tests. Luckily this has allowed me, in consultation with my doctor, to . . . wait for symptoms to appear.

Moreover, overall, it's not clear that the health benefits of catching things early through comprehensive screeening outweigh the health costs of superfluous treatment of conditions that weren't bothering the patient all that much. I'm more than fine with spending a great deal of money on screening if it improves peoples' health, but it's not clear to me that this is the case.

Why does American medicine do so many blood tests, X-Rays, EKGs, and so forth? You can't blame it all on lawsuits; my doctor didn't test me for hyperthyroidism because she was afraid of the malpractice suit that would result from my losing too much weight and getting heart palpitations. Nor can you blame it on money; my doctor doesn't profit from giving me blood tests that all come back normal. And I don't think the lack of rational rationing can be the culprit either. To the extent that insurance companies have bad incentives, it should be to do too little, not too much. They should have incentives to ration this sort of thing, but they don't.

I suspect the ultimate cause is the medical culture, which will make this sort of thing very hard to eradicate in either a single-payer or a private system.

Comments

I think the problem here is that, when considering others as a group, it's fine to think in general, but when considering yourself and you're own health, you're always going to engage the specific. I mean eliminating many needless blood tests might seem great as policy, when it's your blood, it's much harder to say "I don't need this test." And of course, if you eliminate needless testing, you're also ensuring that somewhere along the line, someone will not be tested who would have been revealed to have a dangerous disease. Which would at least be terrible from a PR standpoint, and morally itchy.

Posted by Freddie | September 26, 2007 10:20 AM

The current testing regime for lead in the blood of children (especially those living in older homes) seems like a good idea.

Posted by Amy P | September 26, 2007 10:32 AM

With this: "Nor can you blame it on money; my doctor doesn't profit from giving me blood tests that all come back normal." Do you have any idea how many "doctors" have financial interests in the labs/out-patient specialties thet refer their "patients" to?

Also, there's a 'customer service' aspect to all those tests, scrips, et al., seemingly cost-free, in our third-party payor schema.

As Hallmark liked to remind us: "When you give the Most, you care the Very Best."

Posted by MEH | September 26, 2007 10:52 AM

I don't think it's because doctors benefit directly through profit. However, they also don't "not benefit" by doing it. In other words, because they and you don't feel any direct adverse monetary hit from performing the test... why not perform it?

If it doesn't cost you anything to do... and the culture is that it doesn't cost the patient or doctor anything to perform a test... you'd be stupid not to do it, even if the marginal benefit is negligible.

A private system where costs are more directly bore by the patient (even if later reimbursed by the insurance company) would hopefully help reduce this, and at least make doctors and patients discuss the cost/benefit of tests before performing them.

Posted by Nick | September 26, 2007 11:00 AM

"...my doctor didn't test me for hyperthyroidism because she was afraid of the malpractice suit that would result from my losing too much weight and getting heart palpitations."

Are you sure?

Posted by JJF | September 26, 2007 11:00 AM

As an economist, you should know that if you reduce the cost of something, it will be consumed more. Many of these test are free for people with insurance. So they get them. After all, it just might find something and even a very tiny chance is worth a zero cost procedure, especially if an authority figure in a white coat recommends it. The doctor isn't paying for it, either, and he also just might benefit from finding out something, even if it's very unlikely. And if the test comes back positive (even a false positive), the doctor gets to do more work that may make him more money. Since the insurance company pays for it and not the patient, the doctor can do all the tests he wants without having to worry about bankrupting his patient.

Doctors generally care about their patients healt hand wallets (as in they don't want to force their patients to pay a lot of extra money). My experience, though, is that doctors have an adversarial relationship with insurance companies and probably don't mind screwing them over with unnecessary procedures.

And yes, in the long run, it does come back to the patient, but in a roundabout way. And the patient then gets mad at the insurance company, not the doctor.

It would be nice if, rather than just paying for things, insurance companies charged a percentage or nominal fee for everything. That would at least encourage patients and doctors to give some thought to whether or not a test is necessary.

I'd also like to see a reform of medical billing. As it is, whenever I go to the doctor and get anything tested or any procedure, the bills come weeks or months later and come from entities I've never heard of. This makes it hard for me to know how much things cost. It'd be like going to get your car serviced and getting charges from the auto shop, the technician, the oil supply company, the parking lot where your car sat, etc... instead of just getting a bill presented when you got your work done.

EI

Posted by Earnest Iconoclast | September 26, 2007 11:07 AM

"I suspect the ultimate cause is the medical culture, which will make this sort of thing very hard to eradicate in either a single-payer or a private system."

Medical standards of care are set by various umbrella organizations, such as "The Joint Commission". This seems innocuous enough. Groups of doctors, hospital administrators and representitives of insurance companies argue their way to consensus of what is good medical practice from a medical, moral and economic viewpoint. There is a problem.

These organizations span multiple companies. While individual insurance companies work to keep costs down, they are better served if their umbrella organizations keep costs high. Medical care being expensive makes insurance a wiser investment. I'm not trying to imply a devious level of collusion. These umbrella organisations seem like a perfectly reasonable out growth of the systems that were in play. They are almost certainly of innocent origin, but their effect is harmful.

Kaiser Permanente doesn't profit because it provides more care to its customers for less money in absolute terms. It profits because it does a better job than the other insurer at cutting costs. The higher those costs are in the first place, the more opportunity there is for profit. As long as everyone has the same standards, it is better that those standards be as high as possible, from a money making point of view.

For the actual providers, more business is always good. Nobody in the business of setting standards has a genuine monetary interest in keeping costs down. That is the attraction of single payer. It introduces an entity into the standards-setting game that has an interest in lower cost. It allows the single insurer to genuinely play the part that we always thought the insurance companies played.

Posted by Njorl | September 26, 2007 11:13 AM

But if the single payer is the government, would it really have an incentive to keep costs down? And if it did, would it then have an incentive to take care of the patients? I am not sure I'd trust a government agency to balance the good of the patients with keeping costs down in a way that I found acceptable. Obviously, everyone would have their own idea of what is acceptable. How would a massive government bureaucracy be accountable to patients?

Is keeping the costs down really the primary goal?

EI

Posted by Earnest Iconoclast | September 26, 2007 11:22 AM

Single-payer systems discourage people from regular check-ups (I know from experience) as they do not allocate enough resources to them (they are prioritising on medical urgency) so that waiting times and delays make it very inconvenient. An office visit is normally a full-day off work.

Of course, they *say* they encourage regular office visits for preventive medicine.

Posted by luispedro | September 26, 2007 11:24 AM

"Why does American medicine do so many blood tests, X-Rays, EKGs, and so forth?"

Does this mean, Megan, that you're not going to have periodic breast exams? And if the answer is no, do you think it's a good thing that most medically uninsured women can't afford them?

Posted by Stan | September 26, 2007 11:45 AM

I think one of the primary reasons for routine blood tests is cholesterol screening. It seems to be a good example of preventive care, if you can catch this early and lower through diet, exercise, and drugs when needed you can avoid much more expensive treatments later on in life.
This makes more sense as you get older and chubbier. I don't know that yearly blood tests for healthy fit twenty-somethings are really necessary.

Posted by cdeegan | September 26, 2007 12:11 PM

Whatever excess costs result from unnecessary testing are probably dwarfed by the excess costs resulting from heroic yet futile end-of-life care.

Posted by Peter | September 26, 2007 12:34 PM

How can you discard the lawsuit hypothesis so quickly? Maybe your doctor didn't do that particular test out of fear of a lawsuit, but I think it is a generalized problem.

It sounds like a hypothesis that needs to be empirically tested.

Posted by Francisco | September 26, 2007 12:48 PM

In the case of blood tests - I believe that there would be great benefits to society and science in case one would also document prior consumption and life-style habits. But since this is rarely the case ..

Posted by hugo pottisch | September 26, 2007 12:58 PM

Regardless of the reason, don't be too quick to knock the value of a few normal test results. Every person is different, and a few 'normal' values established over several years is helpful for quickly identifying sudden changes in your health.

Posted by Ryan W. | September 26, 2007 1:14 PM

"But if the single payer is the government, would it really have an incentive to keep costs down?"
Yes. Everyone in government claws at each other to get a bigger piece of the budget. Once your piece of the budget is determined, you try to keep your costs down so you can accomplish your mission.

"And if it did, would it then have an incentive to take care of the patients? "
Yes. Government employees, like patients, tend to be human beings endowed with empathy. Given no incentive to not do their job it is reasonable to expect that they will do it for the incentive of their pay. I know this idea is unpopular, but I see it in practice every day.

Posted by Njorl | September 26, 2007 1:30 PM

If a government agency keeps its costs down, it tends to get a smaller budget next year. Government agencies don't really have much incentive to keep their costs down.

Government employees are very difficult to fire and so don't have a great incentive to do a good job. In fact, laziness might be one reason for them to do an inadequate job.

EI

Posted by Earnest Iconoclast | September 26, 2007 1:37 PM

"a Scottish friend"

Is that the 21st century blogger version of the theatrical tradition of always referring to the Scottish Play?

Besides, we all know you are referring to Alex Massie ;-). (You'll have to excuse me now, as I must go outside, spin around three times and spit over my left shoulder.)

Posted by Internet Ronin | September 26, 2007 1:58 PM

"How can you discard the lawsuit hypothesis so quickly? "

Malpractice costs are very small, ~$6-7 billion in a two trillion dollar industry. Defensive medicine costs are believed to be a small fraction of malpractice costs. General practitioners have significantly lower malpractice costs than the average, which is driven up by OB/GYNs, gastroenterologists, anaestesthiologists, cardiologists and neurologists.

Unless he sits and watches as you collapse on the floor and die, almost no inaction by your GP will be likely to cost him money in the long run.

Posted by Njorl | September 26, 2007 2:16 PM

I had to get a whole slew of blood tests for my first OB appointment, including tests for HIV, syphilis, and chlamydia despite my protestations that I didn't need them. It's VA state law that I be tested for syphilis, and the others were standard for the OB/GYN practice. Never mind that I've had only one sexual partner in my life, and he's only had me.

Then later I got a blood test to screen for spina bifida and chromosomal abnormalities. My doctor told me that I didn't have to get it, though it was strongly recommended, though if I were in CA, I would have to according to state law.

My dad used to get upset that he had to have a prescription to get lab work done. He thought it was quite a racket that forced him to get a prescription for every prothrombin-time test, despite the fact that he had to have them on a bi-weekly basis to monitor the efficacy of the blood thinners he was on.

Posted by Christina | September 26, 2007 3:42 PM

"If a government agency keeps its costs down, it tends to get a smaller budget next year. Government agencies don't really have much incentive to keep their costs down."

You have no idea how it works. Government agencies always spend their entire budget. What they get done with it is the variable. They have incentive to get as much done as possible because they compete with other agencies for a share of government revenues.

"Government employees are very difficult to fire and so don't have a great incentive to do a good job. In fact, laziness might be one reason for them to do an inadequate job."

It isn't nearly as hard to fire government employees as it used to be. More significantly, the new incentive pay systems allow for much more rapid promotion and salary increases than previously. Every government employee is in direct competition with his coworkers for a limited pool of raises and bonusses. Even before this, people did a good job because people like to do a good job.

Posted by Njorl | September 26, 2007 4:28 PM

I've worked at a doctor's office. Two things:

1) Doctors have to look at test results. They are not going to send you off for them for no reason as they are rather busy people. Also, they are not going to incur the cost of extra work on their staff for no reasons.

2) Doctors DO charge for blood tests. I've billed for them.

Posted by NutellaonToast | September 26, 2007 5:15 PM

Just learned about this in medical school. There is a mathematical answer to the question "When should I screen or order tests?" It has to do with the prevalence of the disease, the sensitivity of the test, the likelihood of a false positive, and the cost of screening.

See here:

http://alejandrogonzalez.typepad.com/my_weblog/2007/09/how-to-calculat.html

And here:

http://alejandrogonzalez.typepad.com/my_weblog/2007/09/dont-just-order.html

Posted by Alejandro Gonzalez | September 26, 2007 7:46 PM

"Never mind that I've had only one sexual partner in my life, and he's only had me."

Believe it or not, some people lie. Sex is probably the world's favorite topic to lie about. When the health of a third person, the baby, is at risk, a test is considered to be better than relying on a woman's trust in her husband.

Posted by Njorl | September 27, 2007 2:14 PM

We do a lot of testing because of all of the above; malpractice risk (failure to diagnose), some profit incentive (since most physicians are prohibited from owning an interest in outside labs, it's really only the simple tests we do in-house) and ineffective rationing. About the latter, I am reminded about the furore that arose under capitated systems, when physicians were being asked point-blank if they stood to gain financially buy not ordering a test.

In a system where one is paid a flat rate for a patient-month, the answer is, "yes, what I don't spend on you, i get to keep for my kids college fund." It's really a damned if you do, damned if you don't world.

Oh, and while we discuss culture, which encompasses all the expectations regarding health care, let's include the patients. For every patient who would like to see themselves on fewer meds with fewer tests there are two who would say, "What do you mean I'm not getting a prescription? Or, I added the test myself to the form you gave me. I thought it was important."

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