Medical Excess

An essay in the NYTimes today on doctor excess - how we order too many tests and do too many procedures - a capitalist response to the free-market squeeze of declining reimbursement (physician reimbursement is based on the fee schedule that the federal government sets regarding medicare/medicaid).

What the author, a doctor, does not mention however, is that some of this excess medical service is driven by what we call "cover-your-ass medicine": medical decision making that is driven more by the fear, which is substantiated, of future litigation than by science, evidence, ethics, or sound economic judgment.

Another important factor that plays into excess is the desire of patients to have gilded medical care. Americans have an attitude of entitlement when it comes to medicine - we feel that we deserve nothing less than the best modern medicine has to offer - whatever the cost. This is an immeasurably detrimental attitude because it leads to insane medical practices like spending 200K to keep a dying many alive for a 2 weeks in the hospital when that same money would be more rationally used as a wide-ranging distributive investment in the health of a hundred children.

A third factor is the very poor use of evidence-based medicine to establish practice guidelines for tests and procedures. If there is no indication (reason) for a test or procedure that is based on epidemiological evidence showing improved health outcomes, then it should be the patient's responsibility to pony up the money for the test/procedure if they want it, not the government's or insurance company's. I know there would be a lot of political fighting over those guidelines (insurers will want to save money, doctors will want to ensure they have enough freedom to treat their patients as they see necessary independently of economic considerations), but that is really the only way to reign in excess and still protect doctors legally.