Stirrings of sanity on health-care spending

Doctors sometimes do dumb things. Like ordering antibiotics that are certain to be ineffective. Or prescribing expensive brand-name drugs when cheaper generics would do.

Actions like these are routine in much of primary care. They run up costs while offering no benefit to patients. They can sometimes even cause harm.

A first step toward controlling health-care costs could be to alert doctors to their wasteful ways. Armed with knowledge, physicians might adopt more efficient patterns of practice.

The National Physicians Alliance (NPA), a group representing 22,000 physicians across specialties, recently surveyed experts to identify the most inefficient practices in primary care. The findings were published in the prestigious Archives of Internal Medicine.

NPA highlighted the top five most wasteful activities in each of the fields that make up primary care: family medicine, internal medicine, and pediatrics. These activities have little or no medical value, may present risks to patients, and would be easy to eliminate.

Aside from unnecessary prescribing, here are some of the inefficient actions on NPA's list - routine imaging tests (like X-rays and MRIs) for low-back pain within the first six weeks, full panels of blood tests for healthy adults, annual electrocardiograms for low-risk patients, and indiscriminate use of corticosteroids for children with asthma.

The wastefulness of these practices is obvious to many practicing physicians. So why aren't doctors already taking steps to limit them?

Several reasons stand out. The most obvious is force of habit. It's hard to get anyone, doctors included, to change their ways after years of practice.

Doctors may also feel pressure from patients. Many expect to receive antibiotics, screening tests, and other services without concern that a benefit is very unlikely.

Some doctors also point to defensive medicine. Extra tests reduce the chance of missing a diagnosis, which could lead to a lawsuit.

Behind all of these factors lurks the most powerful one of all. It holds the key to changing the way that doctors and patients behave.

That is the payment system for medical care. Few doctors or patients feel the effects of wasteful treatments, because they don't pay the cost. Patients face the same co-payments and deductibles regardless of whether the care they receive is needed. And doctors can often earn more by doing them.

No one yet has an ideal solution, but efforts are under way to find one. The Medicare program, prodded in part by the health-care law, has experiments in the works, as do several large insurance companies.

It is encouraging that a group of physicians has sounded the alarm about its own profession's behavior.

Apart from the shouting and posturing in Congress, we may be seeing the start of real efforts to bring sanity to health-care spending.

- Robert Field,
professor of law and public health at Drexel University