Why primary care doctors are so busy

During an office visit with your doctor, you might spend part of your 10- or 20-minute appointment discussing your symptoms. The doctor takes notes. A test or a prescription might be ordered. Maybe there’ll be reassurance there isn’t anything seriously wrong with you, or a plan to follow up if there are any concerns.

This is what patients see, and it’s not surprising when they conclude this is how the doctor spends his or her entire day. What they’re seeing, though, is only the tip of the proverbial iceberg. A new study, published this week in the New England Journal of Medicine, quantifies how much time primary care doctors devote to all the extras – extras that are largely invisible to the public and for which they don’t get paid.

The authors asked the question: What’s keeping us so busy? The answer is eye-opening.

The study tracked a private practice in Philadelphia with five internists and an active caseload of 8,440 patients. Here’s how some of the numbers broke down: In 2008 each physician saw an average of 18 patients a day, Monday through Friday and Saturday mornings. Each day they made 23.7 phone calls and received 16.8 e-mails. They reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports, and processed 12.1 prescription refills.

Here’s a further look at just one of these categories, prescription refills:

Each physician processed 12.1 prescription refills per day, not including refills that were handled during a visit or requested as part of a telephone call involving other issues; multiple medications that were refilled at the same time were counted as a single refill. Each refill request required some level of chart review (e.g., determining the patient’s history with the drug and whether any required monitoring had been performed).

What many people may not realize is that physician practices don’t get paid for these tasks. The revenue that’s generated must come from actual patient visits to the office. You don’t have to be good at math to figure out that as primary care doctors spend an increasing amount of time on charting, paperwork, communication and behind-the-scenes patient care management, it means less time for face-to-face care and significantly more pressure on the practice’s overall resources.

Is it all about the money, then? Well, yes, it is, in the sense that practices need to generate enough cash to keep the doors open so they can continue seeing patients. And the more time that’s spent on uncompensated tasks, the more challenging this becomes.

Some medical practices are addressing this by charging office fees or service fees – an add-on to help defray the cost of, for instance, taking care of a prescription refill or sending a lab report. One private cardiology practice in California, for example, this year began charging annual fees ranging anywhere from $500 to $7,500. Patients who don’t want to pay the fee can still see the cardiologist, of course, but as NPR’s Shots blog explains, they’ll face some restrictions, such as limited telephone availability except in emergencies.

The situation is arguably worse in primary care. Over the years, primary care has become increasingly cognitive. It involves managing, coordinating, communicating, coaching – important skills that unfortunately are devalued in a payment system where procedures and office visits reign supreme.

I suspect even the authors of the NEJM study were a little taken aback to discover just how much time they spend on all these invisible tasks. It should be eye-opening for the public as well. Now that we know, it becomes harder and harder to come up with excuses for maintaining the status quo.

Photo: Wikimedia Commons

The healthy bowtie

My youngest brother, who sings in Kantorei, a Twin Cities-based chamber choir, wears a sharp-lookin’ bowtie and tuxedo for concert performances. Aside from this rather rarified example, I can’t think of anyone else I know who wears a bowtie in everyday life.

Not to offend anyone, but bowties other than at a black-tie event strike me as fashion best befitting the nerdy and uptight. Maybe it’s the environment I work in. If a male reporter showed up one day wearing a bowtie, it’s pretty safe to say he’d be laughed out of the newsroom.

Neurologists, though, are apparently a whole different story. I was somewhat stunned to learn yesterday that these specialists are known for their preference for the bowtie. John Gever, who blogs at MedPage Today, writes about his recent discovery of this factoid:

Call me a bumpkin, but I only learned this month that neurologists are famous for favoring bowties.

Actually, “favoring” may be putting it a bit strongly. The American Academy of Neurology’s quasi-official spokesman on neckwear, John C. Kincaid, MD, of the University of Indiana’s medical school estimated that “perhaps every 20th or 30th” neurologist wears one.

But the organization is serious about bowties. It sells an official logo tie – although, it must be said, it comes in the more conventional dangling kind also – that required an AAN committee and two to three years to develop.

Kincaid served on the committee. He told me he was encouraged to do so after he complained about “a heinous decision” to sell a pre-tied version, like the ones that come with cheap rented tuxedoes – anathema to real bowtie wearers.

Kincaid explains that men who wear bowties tend to be rather precise, a description that fits many neurologists. Neurologists also might be emulating some of the worthies in the field, such as Dr. Roger Rosenberg, who are known for wearing bowties, he suggests.

There’s a practical reason too: “A neurologist’s exam often requires close examination of patients’ heads, during which a long tie can dangle in their faces.”

Who knew?

As it turns out, the traditional long necktie can be a genuine liability in patient care. Any time blood or body fluids might be involved, bad things can happen to ties, as the experience of anonymous blogger Charity Doc demonstrates rather graphically (warning: it’s not a story for the faint-hearted).

More to the point, long neckties also can harbor all kinds of microbes. After someone noticed a few years ago that physicians’ neckties often brushed against patients during an exam, a team at the New York Hospital Medical Center of Queens sampled 42 long neckties worn by male physicians, physician assistants and medical students. They discovered that 20 of the ties harbored potentially serious bacteria such as staph, Klebsiella pneumoniae and Pseudomonas aeruginosa. In contrast, ties worn by hospital security guards that were sampled as a control group were eight times less likely to contain pathogens.

These findings don’t automatically mean doctors are transmitting dangerous bacteria to their patients via their neckwear. Hand washing is still the single most important thing health care professionals can do to reduce the risk of spreading infection. But it gives you pause, especially since long sleeves, pens and clipboards also have been implicated as reservoirs of germs that can be spread.

In this context, bowties are a practical solution – not as informal as going tieless but far less likely to flop onto the patient or come into contact with various biological fluids. Maybe they’re not so nerdy after all.

Image: Tyrone Power and his bowtie. Courtesy of Wikimedia Commons

The cost of doing nothing

It has been more than a month since the federal health care reform bill was signed into law. The fallout is continuing; we’re still trying to figure out what the impact and the unintended consequences will be.

What I haven’t seen yet is much discussion of how health care reform will affect rural communities. Will it be a disaster, as some are predicting? Or will it be beneficial, if for no other reason than making health insurance more accessible?

Obesity: where ethics and policy collide

When you hear the word "obesity", what do you think? Do you think about someone with no will power? Someone who’s a drain on the health care system? Do you think parents are negligent if they have a child who’s obese? Do you think we need to take more draconian public-policy measures to prevent and reduce the incidence of obesity?

For many people it’s a black-and-white issue: Obesity needs to be stamped out and society should do everything within its means to reach this goal.

Not to gloss over the health implications of obesity, but I think it’s more nuanced than this. Although it’s not often recognized, there is in fact an ethical dimension to how our society confronts obesity. This intersection of ethics, public policy and individual autonomy is explored this month in a fascinating in-depth edition of Virtual Mentor, the American Medical Association Journal of Ethics.

The journal’s editor, Dr. Fatima Cody Stanford, explains why the topic is so important right now:

It has been widely acknowledged that improvements in American health made by the success of tobacco cessation efforts are under threat from the climbing rate of obesity and obesity-related conditions such as type 2 diabetes mellitus and hypertension. As the topic of obesity takes center stage, ethical treatment, diagnosis, and legislation have become more necessary than ever.

At the individual level, the ethical issues start in the exam room. I don’t think doctors do their patients any favors by avoiding discussion of problems with weight, especially if the patient’s weight might be contributing to a chronic condition. It’s important to recognize, however, that physicians are as prone as the rest of society to bias and stereotypes, and that their biases can unwittingly erode the relationship with the patient.

Consider the case of "Mrs. Williams," outlined in one of the Virtual Mentor commentaries that addresses weight-related stigma and physician bias. Mrs. Williams has been hospitalized multiple times for health issues complicated by her weight. Her doctor tells her that her health will improve if she loses weight; she’s frustrated because she feels all her health issues are being blamed on her weight. When things aren’t going well, the authors write, the common reaction is for physicians to pass some of the blame back to the patient:

Mrs. Williams provides grist for this reaction, since she has an obvious risk factor – her extreme obesity – and has not responded to advice to lose weight. It is important for her caregivers to step back from their emotional reaction to her criticism and her lack of response to their well-meaning advice and decide whether they can examine their own motivations and feelings of inadequacy, put themselves in the patient’s shoes, and do a better job partnering with her in this effort.

There is in fact a significant weight bias among health care professionals and it often spills over into their interactions with patients, explains this Virtual Mentor commentary that examines weight-related stigma, particularly in the doctor’s office and in the hospital. Do health care professionals have an ethical duty to be aware of the extent to which weight bias has shaped their patients’ perceptions of how they’re treated within the health care system? The authors believe the answer is yes.

The issues get especially gnarly when it comes to public policy. By focusing on psychological, rather than sociological, factors for obesity, U.S. policy is misguided at best and ineffective at worst, suggests this essay that contrasts the U.S. approach with that in the U.K.:

We blame the individual – sloth and gluttony are the causes of obesity – and conclude that individual medical treatment is needed if the individual cannot change. In contrast, the U.K. views the problem from a sociological perspective, instituting systemic changes to the toxic food environment felt to contribute to obesity in their nation.

So should we enact more laws – taxing sugary soft drinks, for instance – or does this smack of paternalistic government intervention? To what extent can we – or should we – legislate people’s choices and behavior? Not everyone agrees that policymakers ought to get involved in telling the public what they should eat or how active they should be, explains yet another of the Virtual Mentor commentaries:

Dietary behavior – and to some extent, physical activity – are intensely personal and are influenced by numerous factors, including genetics, biology and environment. At issue is the perpetual tension of pluralistic democracies: identifying an appropriate balance between individual liberty and the well-being of the community as a whole.

At a time when the public discussion about obesity is often characterized by sanctimony and blame, it’s worth reading this entire edition of Virtual Mentor for a more thoughtful perspective.

When we talk about obesity, how much of the conversation is influenced – even unconsciously – by bias? In our zeal to do something about obesity, are we actually helping people or are we just haranguing them? At what point do we cross the line from supporting people to dictating how they should live? How can we address obesity without sacrificing respect for individuals and for their autonomy? How can we do it in a way that’s genuinely beneficial, using strategies proven to be effective? Tough ethical questions, all of these, but questions that need to be asked.

Raising the safety bar

In the retail world, bar coding has been around for ages. It has been slower to arrive in health care, but this technology is finally starting to gain traction as one of the ways hospitals can improve medication safety.

Here in Willmar, Rice Memorial Hospital joined the bar-coding team last week, implementing bar-coded medication administration at the patient bedside.

Many improvements in patient safety are more or less invisible to the public. Not so with bar coding, which patients and families are bound to notice. How it works: Before handing out a pill or hanging an IV solution, nurses will be using a handheld scanner to check the bar code on the patient’s wrist ID and the bar code for each medication to ensure everything matches – right patient, right medication, right dose, right route, right time. If something is wrong, an alert will pop up – yellow, for instance, if the pill is the correct medication but only one pill was scanned when the full dose requires two, and red if the medication is wrong, meant for another patient or some other glitch indicating it shouldn’t be administered.

Medication errors are a big deal. Far and away, the largest number of adverse events in U.S. hospitals involve medication mistakes. Although accurate figures are hard to come by, a report put together a few years ago by the Institute of Medicine estimates that each person who’s hospitalized is at risk of one medication error per day. Other statistics suggest that medication-related adverse events occur in anywhere from 1 percent to 10 percent of all hospital stays. (These statistics don’t even include errors that take place in outpatient pharmacies, nursing homes or other settings.)

When they do take place, these errors can be devastating. At the very least, they can lead to severe effects and require medical intervention, as happened in the case of actor Dennis Quaid’s infant twins, who in 2007 mistakenly received a 1,000-fold overdose of heparin, a blood thinner for preventing clots. And some medication errors are fatal, a lesson underscored with the story of Betsy Lehman, who was being treated for breast cancer and died in 1994 of a lethal chemotherapy overdose.

Getting at the root cause of medication errors is not easy. Mistakes can happen at almost any point in the process. Sometimes the physician mistakenly writes down the wrong dose. Sometimes the pharmacy misreads a handwritten prescription. Sometimes a pharmacist dispenses the wrong drug or the wrong dose. Sometimes a nurse mistakenly picks up the wrong drug, or administers it to the wrong patient. On top of this, health care professionals are surrounded by a busy, distracting environment that increases their risk of basic human error.

Increasingly, the industry has been turning to technology to standardize these processes and reduce the likelihood of certain types of errors. In this context, bar coding makes a lot of sense. The technology is reliable. It’s automated, with less room for human error. Given that errors involving the actual administration of a medication are among the most challenging to prevent, bar coding also offers that final double-check at the bedside, where the process is especially vulnerable.

When you think about it, it’s a little surprising that bar coding hasn’t caught on sooner in health care. Rice Memorial Hospital in fact is among a minority of hospitals where this technology has been introduced.

Bar coding, however, is not as simple as it sounds. When the U.S. Agency for Healthcare Research and Quality reviewed some of the research it has funded on bar coding, it found all kinds of obstacles. In some cases, hospitals bought bar code scanners that turned out to be incompatible with many of the bar codes being used. At many hospitals the workload actually increased because many drugs didn’t come with bar codes or had to be repackaged into unit doses. There’s also the issue of training the staff, providing tech support and having bedside nurses adapt to a significant change in their routine.

This isn’t the kind of change that happens overnight. At Rice Hospital, for instance, the planning process started way back last fall. The fact that Rice has been using an electronic medication administration record and automated dispensing cabinets for the past two years gave it a head start on the introduction of bar coding. Nevertheless, it takes a lot of work to implement this kind of initiative. Information-gathering, evaluation and tweaking of the system will probably continue for many months.

None of us should expect bar coding to be the total answer to medication safety. It’s just one piece in the overall picture. As with any technology, it’s only as good as the humans who design it and the humans who use it. Will mistakes continue to happen in spite of bar coding? More than likely they will. But it’s to be hoped there will be far fewer of them, and that this particular point in the medication administration continuum will become demonstrably less vulnerable to error.

West Central Tribune photo by Anne Polta

A little privacy, please

Back in the day, this newspaper (and plenty of others) used to publish a daily list of hospital admissions and discharges. It had high readership. If it was omitted, which occasionally happened, we could usually count on at least one phone call from a reader, wondering why the “hospital notes,” as they were called, weren’t in the paper.

Over time, though, fewer and fewer hospital patients opted to have their name released. The list got shorter and shorter. By the time we discontinued the practice of publishing it a few years ago, it had more or less lost its newsworthiness.

Even before HIPAA, the Health Insurance Portability and Accountability Act of 1996, came along, health care was evolving toward greater privacy protections for patients. This wasn’t just an industry trend. Expectations of privacy were increasing among the public as well.

In our tell-all age of Twitter and Facebook, it seems counterintuitive that people would want to keep some things private – but when it comes to their health care information, most people are more sensitive about who gets to see it. It’s one thing for them to choose to share their personal stories on their own website or blog, or show a video of their gall bladder surgery at a dinner party. It’s another matter altogether for someone else to go ahead and share it without their consent, especially if the unauthorized sharing is done by someone entrusted with their health care.

The ease with which information can be transmitted electronically has upped the ante considerably. It was inevitable, I guess, that tighter patient privacy regulations would be enacted sooner or later.

HIPAA was a big deal for health care organizations to implement. Now, it has become such a permanent part of the landscape that it’s easy to forget the rules really haven’t been around all that long. It was seven years ago last week that the privacy regulations went into effect, and five years ago this week that the security rules took effect.

It’s interesting to get a behind-the-scenes glimpse of what hospitals must do in order to ensure the privacy and security of patients’ health information. At Rice Memorial Hospital here in Willmar, all staff and volunteers are required to undergo HIPAA training during their orientation and to complete refresher courses as well. Computer access to information is controlled through passwords, filters and user authorization. Audits are conducted on a regular basis. Very few breaches have been reported, so apparently it’s working. And according to hospital officials, both the staff and the public have become much more conscious of privacy since HIPAA went into effect.

HIPAA tends to get a bad rap for being overly burdensome. To be sure, the law is lumbered with a ton of paperwork and requirements. But you don’t have to look far to find examples of why we need it – such as the case of the ULCA Medical Center worker who inappropriately snooped through the late Farrah Fawcett’s medical file. And it’s not only celebrities who can be targets; ordinary patients are vulnerable too, as this case report from the Agency for Healthcare Research and Quality demonstrates. To say the gossip was embarrassing to this patient is an understatement.

Confidentiality has traditionally been more engrained in health care than in other industries. But health care also has had a long history of compromising patient privacy on a daily basis. For the most part it has been done unthinkingly rather than deliberately – a case of “this is just how we do things.”

If you ask patients, most would say the heightened awareness of their privacy has been welcome. Most patients don’t really want to share their hospital room with a stranger – or worse yet, be hospitalized in an open ward. They’d rather not be treated in an open bay in the emergency room. They don’t necessarily want to announce to the whole world that they’re in the hospital or why they needed surgery. They don’t like being rolled on a gurney down a hallway shared by the public. They’re uncomfortable with everyone at their clinic or hospital having access to their latest test results or mental status exam.

HIPAA may be cumbersome. It has been neither easy nor cheap for health care organizations to implement. But there’s a reason why the law was enacted, and it’s for the better that these regulations exist.

Hospital comparisons: behind the numbers

If you have a heart attack or pneumonia, does it matter which hospital you go to? Yes, it does, according to comparative data collected by the Centers for Medicare and Medicaid Services, the federal agency that runs the Medicare and Medicaid programs.

All hospitals do not appear to be created equal, at least when you look at statistics that measure important benchmarks such as whether the appropriate drugs were prescribed, how many patients were readmitted to the hospital within 30 days, and how many patients died. The numbers are publicly reported, hospital by hospital, at the U.S. Department of Health and Human Services’ Hospital Compare website (and summarized here for hospitals in Minnesota; the Hospital Compare website seems to be experiencing some technical difficulties and is not currently available).

This database, and what the numbers mean for patient care, was the subject of an in-depth story this past weekend in the Star Tribune of Minneapolis. From the story:

The two small-town hospitals could hardly be more alike. Just 20 miles apart in southern Minnesota, they’re both run by the Mayo Health System and even share some of the same doctors.

Yet in Albert Lea, patients hospitalized with heart failure are twice as likely to die as those in neighboring Austin, government data show.

That kind of gap may seem improbable, especially in a state known for first-rate medical care. But new ratings published by the federal government have found startling disparities in hospital performance all across Minnesota.

Variation has always been an issue in health care. No two organizations, and even no two individual providers, give care in exactly the same way. In fact, you can make a good case for some degree of variation, because no two patients, and their needs, are going to be exactly alike. Consistently falling well outside the norm, however, is a clear signal that something is amiss.

For this reason, it’s helpful to measure these things. Providers might have an idea where they stand on quality measures, but unless you actually benchmark yourself and compare yourself to your peers, it’s all guesswork. By publicly reporting the results, there’s also an element of accountability, or at least transparency, with the public.

As with any set of statistics, of course, some caution is needed with the interpretation. The data tracked at Hospital Compare, known as core measures, are very specific: If a patient was admitted with a heart attack, did he or she receive aspirin upon arrival? Were aspirin and a beta blocker prescribed when the patient was discharged? Did the patient with pneumonia receive an influenza vaccination? What it doesn’t tell you is whether the patient filled the prescription after leaving the hospital and took the drugs as prescribed. It doesn’t tell you if the pneumonia patient was offered a flu shot and said no. For that matter, it only captures what’s actually documented in the patient’s chart. If smoking cessation was indeed addressed with the pneumonia patient but someone didn’t check the right box, for the purposes of Hospital Compare it doesn’t count.

Demographic characteristics of the community can make a difference in the numbers. It’s rather revealing to see that Hennepin County Medical Center in Minneapolis didn’t fare as well on the mortality rate among heart attack patients over age 65. Does the fact that HCMC is the state’s safety net for the poor and homeless have something to do with this? It should also be noted that percentages can be skewed for smaller hospitals that may see only a handful of patient admissions for acute heart attack or congestive heart failure. In these cases, omitting or not documenting just one core measure can drag down the entire score, sometimes significantly.

It’s important to remember too that the hospital stay is only one point on the health care continuum. If a patient ends up being readmitted within 30 days, poor hospital care might not be the only factor to blame. A crowded schedule at the primary care doctor’s office might mean patients have to wait several days before seeing their doctor for a followup visit. When followup visits aren’t timely, issues with new prescription drugs or emerging complications can’t be addressed soon enough, and patients end up being at risk of a hospital readmission.

That said, it’s enormously helpful to hospitals to know where they stand on these core measures. In fact, the Hospital Compare data is probably far more valuable to hospitals than it is to the public. From the Star Tribune article:

The ratings don’t quite explain why some hospitals perform better than others, and there’s little evidence that consumers use them to shop around for care.

But hospitals are paying attention.

“If I’m running a hospital, I want it to be as good as my neighbors,” said Dr. Gordon Mosser, an expert in quality measurement at the University of Minnesota School of Public Health. “Once the numbers start getting reported, they start caring a lot.”

I’d like to think that if a hospital finds itself out of the norm month after month, it would trigger some soul-searching and a lot of unflinching questions about why this is so – and an effort to change. Likewise, if a hospital consistently does well on the core measures, it’s a powerful reinforcement that good processes are in place and that the staff is delivering high-quality care comparable to the best of their peers.

Over the years, I’ve met very few health care professionals who were OK with being “pretty good” or with working for an organization that’s “pretty good.” The vast majority of them want to be way better than this. If benchmarking and comparisons help spur them toward excellence, it’s a benefit to hospitals and it’s a benefit to patients.

The sedentary life

Next to my computer at home is a kitchen timer. If I plan to spend part of my weekend at the computer, I set the timer for 30 minutes. When it goes “ding!” I know it’s time to turn off the computer and go do something else.

This was one of my New Year’s resolutions this year – to limit how long I sit at the computer and, by extension, to be more physically active.

It’s pretty amazing how much time we spend sitting on our duffs. Television and video games seem to get most of the blame but I think there’s also something else going on: the amount of time, by necessity, the average adult spends in front of a computer screen.

I mean, think about it. We pay our bills online. We do our taxes online. We bank and shop online. We follow the news online. If you’re like me, e-mail and Facebook are probably the main ways you stay in touch with family and friends. (Then there’s my little addiction to Farmville… but I don’t wanna talk about that right now.) One way or another, it’s not hard to rack up a lot of time, on a daily or weekly basis, being sedentary while we deal with the mundane routine of life.

I’m not suggesting we banish computers from our lives. The issue is one of moderation. What’s worth noting here is the importance of moving around – not necessarily running marathons but just being reasonably active throughout the day.

It’s pretty hard to ignore the evidence that has piled up over the years consistently demonstrating that a non-sedentary lifestyle is linked to better overall health and better quality of life. The most recent additions to this body of knowledge appeared a few months ago in the Archives of Internal Medicine in the form of several published studies, most of them looking at the effects of exercise on aging. In an accompanying commentary, the editors note that “the promotion of physical activity may be the most effective prescription that physicians can dispense for the purposes of promoting successful aging.”

Among some of the benefits: improved cardiovascular health, increased endurance, stronger bones, better sleep, reduced stress and better ability to manage weight.

In the national public-health clamor over obesity, it often seems we’ve become so hung up on the numbers on the scale that we’ve lost the ability to put them into context. Yes, we need to do something about obesity. But physical activity is equally a predictor – maybe even more so – of lifelong health. It’s possible, after all, to weigh the right amount yet not be very physically active. It’s just as possible to be overweight in spite of relatively consistent exercise. If I had to pick which of these two examples denoted better overall health, I’d go with the person who maybe weighs a little too much but is physically active.

Getting a move on is not easy. We live in a fast-food environment that makes it difficult to eat as well as we could, and we live in a technological world that makes it difficult for us to be as active as we should. I’m not going to give up my computer any time soon, and in fact I would be at an enormous social disadvantage without it. But we need to be mindful and seek some balance. Sometimes all it takes is setting a timer and then going outdoors on a sunny April weekend and weeding the garden instead.

Image: I Can Has Cheezburger.com

The price is right

If you needed to have an ultrasound or were prescribed an antidepressant, chances are you’d have no idea how much it would cost, nor would you know how to find the answer.

One of the criticisms of the American health care system is that consumers are shielded from the cost. When health insurance pays most of the bill, there’s really no incentive for people to know or care about the price of their care or to make cost-conscious decisions, hence the climbing expenses of the overall system – or so the argument goes.

This might have been true at one time for a significant percentage of consumers. But I don’t think this is any longer the case. Many of us have become highly aware of what we’re paying – not just in premiums but also in rising out-of-pocket expenses. One of the more recent studies, published just last month in Health Affairs, found that almost one in five of non-elderly Americans spent more than 10 percent of their pretax income on health care in 2006. Five years earlier, it was one in seven. These figures came from a survey of 28,000 people under age 65 and include both insurance premiums and direct medical costs.

Clearly a growing number of people are anything but insulated from the cost of their medical care. Just as clearly, it has made only a minimal dent in health care spending. There are some rather startling statistics contained in this report from the nonprofit Kaiser Family Foundation:

Expenditures in the United States on health care surpassed $2.3 trillion in 2008, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980… In 2008, U.S. health care spending was about $7,681 per resident  and accounted for 16.2% of the nation’s Gross Domestic Product; this is among the highest of all industrialized countries.

And hold your horses if you think Medicare and Medicaid are mostly to blame; according to the Kaiser Foundation’s report, spending by these two government programs actually has grown at a slower rate than spending by private insurance.

To be sure, we all need to be conscious of the cost of health care. And compared to even a few years ago, it has become a little easier to search out the price of a service or test. For instance, if you want to know the cost of a hospital procedure, the Minnesota Hospital Association’s price check site can tell you. The Center for Diagnostic Imaging, which operates a medical imaging center in Willmar, is working to develop a price list that tells patients up front what the cost of a CT scan or mammogram will be. A similar pricing initiative is in the works at Rice Memorial Hospital. And I recently ran across Leslie’s List, a free service that compiles information on low-cost testing, prescription drugs and medical services in the Chicago area.

It’s one thing, however, for consumers to know the cost of an office visit or a knee replacement. The real issue, it seems to me, is whether we’re able to use this information in a meaningful way – and I’m not convinced we are.

Networks, tiered pricing and group discounts have benefited insurers at the macro level, but they have obscured the true prices, making it difficult at the individual level for patients to “shop around” and accurately compare. What the provider charges is not what the consumer ultimately pays. Two people can receive the exact same service but one might pay substantially more out of pocket because he or she has a higher deductible or a lesser provider discount.

To a large extent, consumers also are captive to how care is provided. They might be able to choose a hospital or a service based on the total package, but beyond that, there’s very little room for negotiation.

Take, for instance, a knee replacement. Patients don’t get to pick the implant. They don’t get to pick the hospital’s cheapest operating room and OR team. They don’t get to cut corners by skipping the anesthesia, the pre-operative antibiotics or the post-operative rehabilitation. I suppose we could unbundle these costs and give people a menu of choices – first-class vs. coach care, perhaps – but would this be clinically wise? And are consumers equipped to make these kinds of decisions?

How many of us, really, are knowledgeable enough to know what we’re buying? More to the point, how many of us have the wherewithal to be able to define and search out the best health care buys? I frankly don’t know many people who’ll research prices at all the CT scanning facilities in a 50-mile radius and then pick the cheapest/best; most of the time they’ll simply go wherever their physician refers them. Maybe consumers behave somewhat differently in a city environment where there are more facilities to choose from; I’m not sure we can say the same for rural markets with comparatively fewer services.

It’s true that people are often more careful when they’re spending their own money. A $100 copayment to visit the emergency room tends to make us think twice about whether we really need to go to the ER. The introduction of $4 generics was a boon for many people struggling with the cost of prescription drugs.

But if we want to give consumers more control over their health care spending, we also have to accept that 1) they may not know how or be able to make the best decisions; and 2) there will inevitably be times when people can’t afford to be price-conscious. Patients have been known to forego care that’s actually necessary – skipping followup visits, not filling prescriptions – because of the cost, and then winding up sicker at greater overall cost to the system. Financial caution also can become moot when there’s a crisis that demands immediate care. Someone having a heart attack isn’t in a position to shop for the best cardiology bargain. Someone who has been diagnosed with cancer and needs an expensive chemotherapy drug that’s standard first-line treatment will probably opt for the drug, regardless of cost.

If we want to put the brakes on the escalation in health care spending, greater consumer attention to costs undoubtedly needs to be part of the solution. The operative word here, though, is “part.” People might make financial decisions based partly on cost but other things are important too: necessity, convenience, location, personal preference, value, quality, loyalty. A health care service that’s cheaper is not necessarily the better buy. Choosing on the basis of bargain pricing is not necessarily wise.

Here’s the thing: When we view health care as a consumer commodity, something to be bought and sold like a pair of shoes or a platter of ribs, we’re making a fundamental mistake. Health care isn’t a commodity like everything else in the marketplace (and I’m not sure I’d like a health care system that was); it’s a unique and vital service that stands apart. It bears no real comparison with any other industry, and it seems to me we’re misguided in trying to force a consumer model onto a service that defies easy placement in this particular box. By all means, let’s be more price-conscious – but let’s also recognize that the compare-the-costs-and-shop-around mentality has its limits. It’s only one piece in a much bigger and more complicated picture; it’s not The Answer.


compassion: to suffer sorrow for the sufferings or trouble of another or others, accompanied by an urge to help; deep sympathy; pity

What does this word really mean? Here’s one set of reflections from Maria, a psychiatrist who blogs at Intueri. And a response from Shadowfax, an anonymous emergency-room physician and blogger somewhere in the Pacific Northwest.

Go and read both of them. I have nothing more to add.