Health Care Economics V

This is probably the last post for a while on the topic of health care policy and economics, but I wanted to end discussing whether outside parties should influence physician decision making. Let's say there are two equivalent drugs, one much more expensive than the other. Shouldn't we (as a society) limit the use of the more expensive medication to circumstances when the cheaper one fails? Shouldn't we limit the use of brand-name medications to circumstances where there is no generic or the generic fails? How about applying this to surgeries and devices? Imagine if there were a general consensus that no one get elective spine surgery or devices for spinal pain until failing conservative treatment. By avoiding unnecessary high cost interventions, we'd save so much money as a whole. And this could be applied to smaller things as well: what if Medicare didn't reimburse blood transfusions if the hemoglobin were above 8 and there was no acute bleeding? Or if a internal jugular central line was placed without ultrasound, the physician would be penalized?

We are already inching toward this. Financial incentives encourage physicians to practice better medicine; because some nosocomial or iatrogenic occurrences won't be covered by insurance, hospitals have moved to make these events much less likely. There are incentives for us to give peri-operative antibiotics on time, make sure our heart failure patients are discharged on appropriate therapy, and discontinue urinary catheters early. How far should these measures go?

I don't think they will get very far. Physicians hate having their autonomy curtailed. Influenced by past experiences, patient desires, unsubstantiated beliefs, and economic reward, they occasionally prescribe the brand-name drug or more expensive medication even if medically, there is no strong reason for it. They will continue to operate, order radiology tests, and recommend surgeries even if this costs the system. We believe medicine to be too complex for algorithms or generalizations or blanket rules. And trained as independent critical thinkers, we resent the fact that non-physicians try to regulate what we can and cannot do. Furthermore, in most cases, it's unclear that a regulatory agency, insurer, or policymaker can determine a universal approach to a problem. For example, I don't think checking PSAs as a screening tool makes sense, and it certainly costs the system a lot. But if Medicare were to stop reimbursing PSA screening, we'd have a outcry of disbelief. Primary care physicians and urologists would come out of the woodwork with stories about how they saved someone's life by checking it. Though it may save the system a lot of money, physicians will fight tooth and nail to prevent a government agency, insurance company, or other entity from making medical decisions for them.