A forum to note and discuss new developments in health services research, as well as other issues pertinent to academic health services research.
Tuesday, September 27, 2011
Arch Intern Med -- Reasons for Overtreatment: Comment on "Too Little? Too Much? Primary Care Physicians' Views on US Health Care", September 26, 2011, Grady 171 (17): 1586
As a primary care provider I agree with the findings of this study. Our medical system supports overtreatment of patients due to litigation risk, incentives. decreased time with patients and clinical performance measures.
To take each one at a time, the risk of litigation increases the practice of defensive medicine. Labs and studies are over performed to decrease the risk of missing a diagnosis. Of course, more testing leads to more lab errors which in turn causes more testing. Also, as a primary care provider, I am more likely to refer a patient to a specialist early to avoid a delay in diagnosis and any blame that may bring on me.
As far as incentives are concerned, I have little experience with these as I am paid by the federal government. It stands to reason, however, that incentivizing providers to perform tests and studies would increase the utilization of tests and studies. I see that this is true with subspecialists, who are more likely to do procedures because they pay so well.
I believe that decreased time with patients is a problem especially for those in private practice. My doctor spends about 5 minutes with me and typically refers me to someone else (I'm probably an outlying though, as I only go to the doctor for orthopedic issues!). In the academic setting I think this is less of an issue. The move to same-day (within 24 hours) appointments as part of the new medical home initiatives will likely make this worse both in private practice and in the academic setting.
Clinical performance measures are a double-edged sword. I personally dislike them because they treat different individuals as if they are the same. As an example, I recently received a letter from an insurance company informing me that me 19 year old female patient had not been screened for chlamydia this year ( the clinical performance measure in this case is annual screening for sexually active females). I had seen this patient once and did not have suspicion that she is sexually active (she told me she is not sexually active which I had put in my note). I put in a note in the EMR to have her screened for chlamydia at her next appt, and she was screened soon after that time. In my opinion, the test was unnecessary and did little to help me take care of this patient. I do understand the desire for evidence-based practice, but the truth of the matter is that most clinical encounters fall outside of areas that have solid evidence-based research behind them. The idea that we will have evidence to back up every clinical decision is not realistic.
In conclusion, it is very true that patients are overtreated. Policy makers in government need to ignore the political clout of trial lawyers and push tort reform legislation as a first step. Also, incentives and clinical performance measures need to be well thought out. If possible, clinical performance measures should be developed by clinicians for clinicians and only in areas where solid evidence exists. Unfortunately, I'm not sure we can ever return to a system where doctors have more time with patients. There are simply too many patients, too few primary care doctors and too much regulatory burden to go back to the way medicine used to be practiced.
As a primary care provider I agree with the findings of this study. Our medical system supports overtreatment of patients due to litigation risk, incentives. decreased time with patients and clinical performance measures.
ReplyDeleteTo take each one at a time, the risk of litigation increases the practice of defensive medicine. Labs and studies are over performed to decrease the risk of missing a diagnosis. Of course, more testing leads to more lab errors which in turn causes more testing. Also, as a primary care provider, I am more likely to refer a patient to a specialist early to avoid a delay in diagnosis and any blame that may bring on me.
As far as incentives are concerned, I have little experience with these as I am paid by the federal government. It stands to reason, however, that incentivizing providers to perform tests and studies would increase the utilization of tests and studies. I see that this is true with subspecialists, who are more likely to do procedures because they pay so well.
I believe that decreased time with patients is a problem especially for those in private practice. My doctor spends about 5 minutes with me and typically refers me to someone else (I'm probably an outlying though, as I only go to the doctor for orthopedic issues!). In the academic setting I think this is less of an issue. The move to same-day (within 24 hours) appointments as part of the new medical home initiatives will likely make this worse both in private practice and in the academic setting.
Clinical performance measures are a double-edged sword. I personally dislike them because they treat different individuals as if they are the same. As an example, I recently received a letter from an insurance company informing me that me 19 year old female patient had not been screened for chlamydia this year ( the clinical performance measure in this case is annual screening for sexually active females). I had seen this patient once and did not have suspicion that she is sexually active (she told me she is not sexually active which I had put in my note). I put in a note in the EMR to have her screened for chlamydia at her next appt, and she was screened soon after that time. In my opinion, the test was unnecessary and did little to help me take care of this patient. I do understand the desire for evidence-based practice, but the truth of the matter is that most clinical encounters fall outside of areas that have solid evidence-based research behind them. The idea that we will have evidence to back up every clinical decision is not realistic.
In conclusion, it is very true that patients are overtreated. Policy makers in government need to ignore the political clout of trial lawyers and push tort reform legislation as a first step. Also, incentives and clinical performance measures need to be well thought out. If possible, clinical performance measures should be developed by clinicians for clinicians and only in areas where solid evidence exists. Unfortunately, I'm not sure we can ever return to a system where doctors have more time with patients. There are simply too many patients, too few primary care doctors and too much regulatory burden to go back to the way medicine used to be practiced.