Friday, 25 March 2016

Overuse and waste in the health care system.

   When I opened the journal 'Canadian Family Physician' this week, I was not surprised to find that the topic of the 'op-ed' was the expense of health care.  I learned some interesting facts.  In Canada, on average, the provincial governments direct about 40% of  their budgets to health care.  Hospitals account for about 30% of that, drugs 16% and physician services 15%.    Based on American studies, there emerges a category of health care consumers labelled 'super-utilizers'.  (Had their English been more correct they would have called them 'super- users', but that's another topic.)  Super-utilizers are the 1% of patients who consume between 30 and 50% of health care resources.  Comparable figures for Canada are not available, however on an anecdotal basis after fifty plus years of medical practice there is no doubt that a comparatively small number of 'frequent-flyers' consume a disproportionately high percentage of the resources. Now, some of the super-utilizers have a completely valid basis for consuming mammoth resources.  There are many life-threatening or severely debilitating conditions that justify such use and other than providing them in the most efficient and cost effective way there is little more we can do.  On the other hand, there are a significant number of patients who are very heavy users of the resources when medically there is no basis for it.  I am  not saying that these people do not require help of various kinds, I am saying they are using very expensive and scarce resources when a lesser level would serve them as well or better.  It compares to having a nuclear scientist fix your toaster.  If you have to pay the bill yourself you'll get an electrician or perhaps a handyman.  These users deprive the really needy from receiving the care they need in a timely fashion.  Devising an efficient way to deal with this will not always be politically expedient even though urgently required.  So the politicians and their janissaries are desperately seeking a way to get this monkey off their back and onto guess who's?
   The second article in this Family Medicine Journal, was titled  'Addressing  overuse starts with physicians'.   While some of the points are valid, their presentation left me with the feeling that even the two physicians in the five- authored paper did not grasp what it is like to run a busy general practice.  'Choosing Wisely', is a program which, in addition to recommending which tests should be done and which should not be done in various scenarios, depends heavily on an exchange between a reasonable physician and a reasonable patient to decide which tests should be done and which omitted.  Even then, in some cases common ground will never be found. Some patients feel their google search is equal to their doctors degree.  In many cases it may require a considerable amount of time to negotiate, in a setting in which the physician is trying to fulfill the requirements of his  EHR (electronic health record) , another time consuming activity and deal with all of  the other concerns of the patient.  This is likely to have an impact on the number of patients the physician can see in a day.  In a province such as Ontario, where disillusioned physicians are already dealing with significant income cuts, it is unrealistic to expect them to increase their losses by reducing patient volume.  It is also likely to increase waiting time to get an appointment. 
    Unfortunately, in this litigious age there is a strong need for physicians to protect themselves.  No physician is going to be exonerated for not performing a test because it appeared it was probably not necessary.  Lawyers are advertising every day that there is money to be made by medical litigation.  This is one of the urgent matters that the department of health will have to deal with, if they don't  want 'Choosing Wisely' to simply peter out after the initial furore.  In addition, there are situations in which the demonstration of a normal test result is therapeutic to both the patient and their family.  I could go on, but just want to demonstrate that sitting in the physician's chair is much different from sitting in the administrators chair.   
   Every patient is an individual, and 'one size fits all' solutions are not available.or desirable, no matter how much money they save. 


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