RINGEL, STEVEN P. MD
Dr. Ringel, associate editor-in-chief of Neurology Today, is professor of neurology and director of the neuromuscular division of the University of Colorado-Denver in Aurora, CO.
Everywhere we turn these days, someone is talking or writing about health care reform. Although there is no consensus on the design of our future health care system, several basic assumptions are widely held and undoubtedly will influence redesign efforts: (1) the rising cost of health care is unsustainable and must be curbed; (2) there is no proven link between more spending and better health care; (3) the quality and amount of medical care provided varies widely throughout our country so that more standardized approaches are needed; and (4) our current payment system does not adequately reward quality or efficiency. Regardless of the final outcome of Congressional efforts to redesign the health care system, there is little doubt that the way we practice neurology will change.
What then can the neurologic community do to address these inevitable changes? Several neurologists as well as other specialists have been in the national spotlight to suggest next steps. In the June 17 JAMA, Robert H. Brook, MD, vice president and director of RAND Health, pointed out that one of the first things we can do is to scrutinize the decisions we make daily in caring for our patients. All of us see wasteful tests and treatments ordered every day. Reducing unnecessary care is not as difficult as it may first appear and it can result in large savings.
As a starting point we have to take the time to educate ourselves on the relative value of everything we prescribe. We can't rely on politicians, regulators, and insurers — or wait for legislative mandates — to decide what tests and treatments are effective; it's our responsibility, and there is much to learn. Instead, we have to roll up our sleeves and work to identify the value of the services we recommend to our patients. It is often said that the most expensive tools that physicians use are their pens. How many times have you seen a patient with migraine headaches who has had repeatedly normal brain MRIs? Or worse, we all know of scans showing typical nonspecific white matter lesions that are misinterpreted as multiple sclerosis, engendering more tests, false diagnoses, and many anxious patients.
Was it Einstein who said that madness is doing the same thing over again expecting a different result? As a neuromuscular specialist, I am regularly referred patients with diabetes who have had a laundry list of tests performed — all normal — looking for other causes of their neuropathy beyond the obvious diabetes.
No matter what the neurological symptoms and signs are, for decades we've trained neurologists to leave no stone unturned. Our patients have also learned to expect no less. Many of us who read the New England Journal of Medicine Clinical Pathological Conferences were taught that competent physicians must consider all diagnostic possibilities. Our entire educational model is built on that premise and reinforced by patient expectations that we helped to create. But none of us paid attention to the cost of what we were ordering, and we were not taught the probability of a positive result with each test or treatment we prescribed.
Using data developed at Dartmouth on regional variations in health care, Atul Gawande, MD, in the June 1 New Yorker, described the overuse of medical services in McAllen, TX. The article has been widely quoted by policy wonks, including President Obama, and somewhat unfairly implies that much of the unnecessary care is a result of physician greed. I believe that there are other equally important reasons why physicians provide ‘unnecessary’ care: lack of evidence for cost-effectiveness, fear of litigation, perverse financial incentives and, to return to my theme, mindless repetition of established routine. As a neurological educator, I plead guilty to having added to the problem over more than three decades. I've taught countless neurologists to consider every possibility without providing them with comparative costs and outcomes when they do what they are taught.
So how do we turn this ship around and provide neurologists with good comparative effectiveness data? To begin this effort, we need to take more immediate steps to address the biggest problem driving the need for health care reform — it's less about perceived deficiencies in the quality of care we provide and more about the cost of what we do.
Although some will be quick to point out that we lack “class 1 evidence” for much of what we currently recommend, I believe that every field of neurology could create in short order a rough hierarchy of the most cost effective to least cost-effective diagnostic and treatment approaches for most patients we treat. For example, neuromuscular specialists could review all the tests performed on their last thousand patients with a neuropathy to estimate the value of each test ordered. Similarly, headache specialists could begin to define a cost-effective approach to managing patients with migraines. All of these initial efforts would, over time, be refined as further outcome data become available, but we can't wait for valuable but time-consuming evidence based guidelines for the neurologic community.
Figure. DR. STEVEN P...Image Tools
Former AAN President Tom Swift, MD, has often said that neurologists always find a way to make a living. As reimbursement for the time we spend with patients has fallen, we see patients more quickly or perform more lucrative procedures. But as Abraham Verghese, MD, pointed out in a June 22 article in the Wall Street Journal, the fallacy of this approach is that we are reinforcing a system that rewards us less for something we do for a patient and more for something we do to a patient.
As AAN President-elect Bruce Sigsbee, MD, pointed out in recent Congressional testimony, neurologists want to be paid for the valuable evaluation and management services they provide to their patients. If we are committed to identifying more cost-effective approaches, we will be an integral part of the solution to today's health care crisis.
President Obama has stated that the reimbursement system for health care is a model that has taken the pursuit of medicine from a profession — a calling — to a business. In a nationally televised ABC News Health Care Forum in late June, Obama was asked penetrating questions by two university-based neurologists. Orrin Devinsky, MD, from New York University, was concerned that the Obama plan would force average Americans to make sacrifices that wealthy and powerful people would never face. He asked the President if he was willing to make the same sacrifices with his family's medical care. John Corboy, MD, from the University of Colorado-Denver, followed up by asking what the president could do to convince the American public that there are limits on what we can pay for in our health care system. Not surprisingly, the president side-stepped the questions. Neither he nor any other politician is likely to address this reality candidly in advocating for change fearful that Americans will rebel.
As physicians, we know that the information we currently have available to weigh the value of the services we provide is rudimentary. We cannot, however, use these limitations as a reason for failing to act.
Universal health insurance won't solve the issue of runaway health care costs anymore than our current fragmented system. Adoption of constraints based on probability and cost-effectiveness will undoubtedly harm some people regardless of how much politicians shy away from discussing this reality. Despite these real concerns, the public must be educated about the inevitable consequences, both positive and unintended, of reducing the cost of health care. As physicians, we are in the best position to provide that guidance as we strive to provide the highest quality care delivered at the lowest cost.•