Over or under use of medical services?

[Martha]

The issue of whether people in the US over consume medical care has come up from time to time in various threads. There is a brief article in the WSJ today that says:

Many patients stop taking their medicine far sooner than they should, researchers say, and that decsion can be deadly when the drugs treat heart disease or diabetes.

One out of eight heart attack patients quit taking their medications within one month of leaving the hospital. These patients were three times more likely to die during the next year than paitents who stayed on the drugs.

Information is from the Archives of Internal Medicine. http://archinte.ama-assn.org/current.dtl

I wonder how the so called "consumer driven" high deductible health care plans will play into this issue. If you are middle or low income, and have a large deductible to "encourage comparison shopping" I wouldn't be surprised if instead of shopping the patient simply omits the necessary care. Gee, why take a pill that makes me feel bad and costs a lot of money?

 

[Nords]

I wonder how the so called "consumer driven" high deductible health care plans will play into this issue.  If you are middle or low income, and have a large deductible to "encourage comparison shopping"  I wouldn't be surprised if instead of shopping the patient simply omits the necessary care.  Gee, why take a pill that makes me feel bad and costs a lot of money?

Sounds like a pretty Darwinian solution...

 

[Rich_by_the_Bay]

Medication compliance is worst when the indication for the drug is clinically inapparent. Such is the case for hypertension, hypercholesterolemia, and antibiotics where patients stop the drug after symptoms are gone but before complete eradication has occurred. Other predictors of noncompliance include frequency of administration (daily is better than twice daily; weekly better than daily), and out-of-pocket cost. Social disruption and mental illness also contribute. These are all intuitive to me. We are not very good at improving compliance (Interventions to enhance patient adherence to medication prescriptions: scientific review. McDonald HP; Garg AX; Haynes RB, AMA 2002 Dec 11;288(22):2868-79).

On the other side of the coin are patients who come to see the doctor for "everything." When they have excellent coverage such as an HMO or even Medicare, this becomes problematic. During my decades in primary care, I had many who would come in for a cold, then come in 7 days later to be sure the cold is completely gone, or for a simple sore muscle after unaccustomed activity, etc.

In that group you have to be on the alert for masked depression, domestic abuse, etc. But even after factoring that in, some just seemed to enjoy the attention and would be glad to talk your ear off all day (we are not as smart as our attorney friends who can charge by the hour ). Most of us agreed that a copay of $20 or so is a good idea in the HMO contracts for that reason.

Still others would schedule a routine follow-up (20 minutes in my practice) and upon arrival would break out a list of 6 or 7 important issues they wanted addressed, and would be dissatisfied if you drew boundaries (like, "these are all important so why don't we arrange a follow-up visit so we can give them the attention they deserve"). You just learn to deal with it with experience.

Yes, consumer-driven care has its merits but incentives need to be in place to use the system appropriately. Kaiser did lots of work on this side of things, but did not achieve dramatic results in most cases. It is one of the important reasons why nurse practitioners found a niche in primary care - they see lots of patients who, by common sense, probably didn't need a visit at all.

This is a complicated profession.

 

[Nords]

Most of us agreed that a copay of $20 or so is a good idea in the HMO contracts for that reason.

About 10 years ago a Fidelity VP sent letters to 30,000 of their customers who were making way too many phone calls. The letters said that if they continued their current call volume then they'd be charged service fees.

IIRC about a tenth of those "problem" customers pulled their accounts and generated a lot of bad press for the company. However those original 30,000 accounted for something like 90% of Fidelity's call volume, so when the rest went silent then Fidelity saved a ton of money.

Patients shouldn't be discouraged from seeking medical care (especially when delay makes the treatment more expensive), but a similar copay system might discourage abuse. Maybe $20 for the first visit, raised by a percentage or some other system for subsequent unecessary visits? I'd rather pay a bigger copay than a higher monthly fee.

The challenge to that fee structure would be liability & malpractice. That seems to be a huge problem with the entire American medical system... and I wonder if it's such an issue in other countries. I suspect that tort reform is an oversimplified solution to a very complex problem.

 

[MasterBlaster]

Patients shouldn't be discouraged from seeking medical care (especially when delay makes the treatment more expensive), but a similar copay system might discourage abuse.  Maybe $20 for the first visit, raised by a percentage or some other system for subsequent unecessary visits?  I'd rather pay a bigger copay than a higher monthly fee.

Perhaps a better solution would be that the more you go see your doctor the longer you have to wait in a dingy office before you get to see the doctor.

Start out with a 30 minute wait and then increment the waiting period by 30 minutes every visit.

If you want to shorten your wait you could see a progression of lesser and lesser care-givers. First the nurse practitioner. Then the nurse in training. That would be then followed by the gal who does the insurance work followed by the gal who (sometimes) answers the phone. A few more would follow including Aunt Sally who just knows what's ailing you. lastly you could see the bum who sleeps in the alley behind the center. 

 

[Martha]

In that group you have to be on the alert for masked depression, domestic abuse, etc. But even after factoring that in, some just seemed to enjoy the attention and would be glad to talk your ear off all day (we are not as smart as our attorney friends who can charge by the hour ). Most of us agreed that a copay of $20 or so is a good idea in the HMO contracts for that reason.

Funny thing is that we get clients like that in the legal profession too. Sometimes I bill my time, sometimes not. Depends on the client. There are always a few people who clearly have problems that are not legal problems, but who persist in calling and calling. Eventually you have to cut them off.



Rich, do you know if the development of hospital urgent care (apart from the emergency room) has helped save money and better allocates resources? It seems logical that it would. But on the other hand, maybe just more people use urgent care that ordinarily would have gone to a primary care physician instead of an emergency room.

MasterBlaster, you're funny. I have been tempted at times to use your strategy.

 

[razztazz]

hypercholesterolemia

Stupid to treat for this is almost all cases. Need physical data on the patient not Russian Roullette based on "madison avenue style" "risk factors". I have had my health ruined, cannot work, will be on drugs for a long time, and still need surgery to correct for lowering my cholesterol.
(I will not get the surgery because I do not trust the doctors or hospitals to do it)

Subsequent heart scans showed no plaque burden. So I was medically f'd for nothing. Some phantom "risk factor". Several hundred thousand dollars of tests and ill advised treatments for things that turned out to be adverse drug reactions. How much does this add to the annual health care bill? Wasn't there a study some yrs back that showed properly prescribed and used ordinary drugs were the #4 cause of death?

If you are middle or low income, and have a large deductible to "encourage comparison shopping" I wouldn't be surprised if instead of shopping the patient simply omits the necessary care

WIth that will have to be laws and Government regulations to force the system to make immediately available and clear as a bell just what the price is. That doesn't exist now. It's a big secret. All they wnat to know is INSURANCE becaus ethey know they can milk that. They don't know how much money YOU have. No "free market" will force them to do it without a gun. You know their motto: Caveat emptor. So we already KNOW where THEY"RE coming from

Maybe $20 for the first visit, raised by a percentage or some other system for subsequent unecessary visits?

So, how would anybody know their chest pain is frivolous or not? What's an unnecesary visit? Who says? And if you wanna pull that make sure everbody knows which ones are unnecessary BEFORE they leave the house so they can properly "marketize" that 20 bucks into their decision making.

Besides, if you are over 40 you can bet your ass they will invent something to make it a "real visit". Hey man, you're cholesterol's too high. I dont know what it is but it's too high. Everybody's is too high. Don't you watch televsion?
I heard something with that stethoscope. You should have a quick X-Ray.

 

[Khan]

hypercholesterolemia

Stupid to treat for this is almost all cases. Need physical data on the patient not Russian Roullette based on "madison avenue style" "risk factors". I have had my health ruined, cannot work, will be on drugs for a long time, and still need surgery to correct for lowering my cholesterol.
(I will not get the surgery because I do not trust the doctors or hospitals to do it)

Subsequent heart scans showed no plaque burden. So I was medically f'd for nothing. Some phantom "risk factor". Several hundred thousand dollars of tests and ill advised treatments for things that turned out to be adverse drug reactions. How much does this add to the annual health care bill?

The perfect disease.

No symptoms.

Drugs to correct it (which seriously mess with your liver et al and which have to be taken for the rest of your life).

Change a number or two on a report and voila: several hundred thousand more 'victims' of a horrible disease need lifetime treatment.

 

[Caroline]

I'm sure there are folks who spend too much time at the hospital for small medical matters. I fall into the other camp.

I try to stay OUT of Kaiser's system as much as possible -- the 45-minute parking marathon, the additional 45-minute wait to see the Dr... 15 minutes to get back OUT of the parking structure (that they've been working on for the last 5 years). Optional visit to the pharmacy (because if I order by phone or mail they'll take three weeks to get it to me) for another 30 minute ding and a healthy(!) coffee and donut to break up the wait.

I've found that I have a lot of trouble avoiding this mess. If I call the advice nurse for the simplest thing and she tells me I need to come in. I see my GP (who I love) who refers me out for ANYTHING to the GYN or the PT or whoever... Each time, it's a $20 co-pay ding and 2 more hours of my time -- and I live 5 MINUTES from the Kaiser Center.

I'm not convinced that the patients are the entire problem. If I owned a manufacturing plant my job would be to book as much business as I could to keep the expensive equipment going 24x7. I'm guessing it's the same for a hospital -- the Drs and staff get paid whether or not their dance card is full, so management works to book 'em up.

 

[AltaRed]

Rich, do you know if the development of hospital urgent care (apart from the emergency room) has helped save money and better allocates resources? It seems logical that it would.  But on the other hand, maybe just more people use urgent care that ordinarily would have gone to a primary care physician instead of an emergency room. 

I can say that in Canada, the development of urgent care clinics has taken a siginficant load off hospital ERs. AFAIK, the health care system likes it and the patients like it. As one example....

DW had a health issue that we considered serious enough to go to ER at the hospital, but we went early in the day to miss the crowd that tends to show up after 10am. Still, parking was difficult and the parking charges added up with the overall experience taking 2-3 hrs in total.

Then just a month or so ago, I had a health issue that I felt required same day attention but chose to go to a suburban 'urgent care' clinic . Free parking and I was in and out in an hour.