ARTICLE IN BRIEF
What do you tell patients when they want the most expensive, not necessarily cost-effective care? Neurologists offer advice, as the AAN and other organizations focus on promoting evidence-based care as part of the “Choosing Wisely” initiative.
Patients want physicians to be their advocates for the best medical care, regardless of cost, and are averse to considerations of expenses — even when they are being borne by insurers — in discussions about options for clinical care.
That was the finding from a February study in Health Affairs in which focus groups of insured individuals were asked to consider scenarios in which they had to choose between options for clinical care that were only marginally different in effectiveness but extremely different in cost.
For instance, patients who were asked to consider whether to have a CT scan or an MRI for severe headache — even when it was explained to them that the more expensive MRI was not likely to find anything more clinically meaningful — tended to prefer the MRI and resisted considerations of cost.
Study authors and neurologists who reviewed the report for Neurology Today agree the findings present a challenge to delivering cost-effective care. But they also say clinicians can reframe what it means to be the patient's advocate, emphasizing that many of the most wasteful procedures are actually clinically pointless or even harmful.
And they can refocus the clinical conversation on the sturdiness and endurance of the doctor-patient relationship, assuring the patient, “I will always be here for you” — as opposed to the performance of expensive procedures — as the measure of a physician's professional responsibility.
“That trust that the doctor is going to be there for the patient regardless has been replaced in patients' minds by a belief in the magic bullet of some procedure that will cure them,” said neurologist Gary Franklin, MD, MPH, research professor of environmental and occupational health sciences at the University of Washington, in an interview with Neurology Today. “But patients rely on their doctors. If they are saying they want an expensive but unnecessary test, I can tell them there is no evidence for the test's effectiveness. But more important, I can assure the patient I will be there for him or her and will see the patient again.”
RESPONSE FROM FOCUS GROUPS
In the Health Affairs study, insured patients from Washington, DC, and Santa Monica, CA, were selected to participate in 22 focus groups. Participants were presented with scenarios in which physicians talked with patients about diagnostic and treatment options that differed marginally in expected effectiveness but varied substantially in price.
In one scenario, participants were asked to imagine that they had had an unusually severe headache for three months, for which their doctor was recommending either a magnetic resonance imaging study or a CT scan. The doctor explained that the difference between the two is marginal: “The MRI presents a slightly more detailed picture and might find something that the CT misses, such as an extremely uncommon blood vessel problem, but nearly all problems serious enough to need treatment would be seen on either the MRI or the CT.”
In one variation of this scenario, the CT scan would cost $400 out of pocket, whereas the MRI study would cost $900. In another, the patient would pay $70 for either test, but the insurer would have to pay $330 for the CT scan and $830 for the MRI study.
Most participants were unwilling to consider costs when deciding between nearly comparable options and generally resisted the less expensive, marginally inferior option. There were four times as many negative comments as there were positive ones on the theme of willingness to discuss costs. Comments indicating an unwillingness to accept the less expensive option outnumbered comments expressing willingness three to one.
Among the comments from the focus groups, participants said: “I want the best health care. Money's no [object]. Either pay the best, or maybe they even miss something with the other scan.”
And: “I don't want the doctor practicing in terms of numbers, financial numbers. I want him telling me as if money is not an issue.”
Study co-author Susan Dorr Goold, MD, professor of internal medicine and health management and policy at the University of Michigan, said the stridency of comments was unexpected. “It was not surprising to us that patients would express an unwillingness to consider cost when talking about their health,” she told Neurology Today. “But we were surprised by the strength of the results and the vehemence of some of the comments. There were some fairly dramatic statements.”
Some participants expressed anger toward insurance companies — or at least a sense that paying for the costs of medical care is what insurance companies are supposed to do. Said one participant: “It could cost them $10,000 and so be it, that's why I'm paying my premium.” And another said, “We feel like we've been gouged for all these years.”
“We were surprised by the issue of ‘getting back’ at insurers,” Dr. Goold said.
Regarding the responses about choosing between a CT scan or MRI for severe headache, Dr. Goold said she suspects they may reflect the concern or fear patients may naturally harbor about any kind of problem possibly related to their brain — a fact relevant to neurology.
“The brain is especially important to people and anything that might threaten the brain is especially bad,” she said. “For that reason, patients may say they prefer a much more expensive test or procedure even if it's only marginally more effective. I don't know if there would be the same insistence for something like, say, toe fungus, that is clearly not life threatening.”
NEUROLOGISTS WEIGH IN
Neurologist Ray Dorsey, MD, who reviewed the report, said he believes the study shows that patients clearly expect their physician to be — first, last, and always — the advocate for their health, not for society. “But being the patient's advocate doesn't mean giving the patient everything the patient says he wants,” said Dr. Dorsey, associate professor of neurology and director of the Johns Hopkins University Parkinson's Disease and Movement Disorders Center.
But Dr. Dorsey also said he believes patients are not the ones to blame for wasteful spending on unnecessary procedures; rather, the problem is the reimbursement system that has incentivized physicians to perform the costliest procedures regardless of whether there is evidence for effectiveness. “The reason clinicians do not choose wisely has nothing to do with patients being ignorant or not understanding cost-effectiveness, and the answer to this problem is creating incentives for physicians to make better choices,” he told Neurology Today.
In fact, in February, a panel of experts from the AAN participated in “Choosing Wisely,” a campaign developed by the American Board of Internal Medicine Foundation in collaboration with consumer groups including Consumer Reports, to develop recommendations for clinicians about questionable practices and procedures that should be avoided.
The AAN group released recommendations about five questionable practices/procedures: don't perform electroencephalography (EEG) for headaches; don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms; don't use opioid or butalbital treatment for migraine except as a last resort; don't prescribe interferon-beta or glatiramer acetate to patients with disability from progressive, non-relapsing forms of multiple sclerosis (MS); and don't recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate is low (less than 3 percent).
[For more on the panels five recommendations, see “CHOOSING WISELY: 5 Things Neurologists and Patients Should Question”: http://bit.ly/15AZz1V.]
As part of the campaign, other medical specialties have also made these recommendations relevant to neurology: don't do imaging for uncomplicated headache; don't do imaging for low back pain within the first six weeks, unless red flags are present; don't obtain imaging studies in patients with non-specific low back pain.
Neurologist S. Claiborne Johnston, MD, PhD, director of the Clinical and Translational Science Institute at the University of California, San Francisco, described some of these procedures as the “low hanging fruit” of costly, unnecessary medicine, and emphasized that in conversations with patients clinicians should be able to explain that these are not just expensive, but pointless or even harmful.
“We have to change the conversation away from ‘don't get this MRI because it's expensive,’ to ‘don't get it because it is likely only to find things that aren't relevant to your symptoms, and we are better off not doing it for your own health.’”
He added: “This is true of the most wasteful things we do in medicine. Why would anyone give an EEG to someone with a headache? It's silly. We need to remind our practitioners that they shouldn't be doing things that are clearly not indicated.”
Dr. Johnston said there are certainly far more difficult “close calls” between more expensive but only marginally more effective procedures — especially in cancer and end-of-life care — when patients or families may expect the costliest option. But he said the medical community has plenty of work to do in the meantime eliminating wasteful and really ineffective tests and procedures.
Dr. Franklin agreed. “Doctors have to take responsibility for this,” he said. “We can't expect patients to know more or have more wisdom than we do. If a doctor knows that an MRI scan does not need to be done in the first six weeks after a back injury unless a patient has red flags, then they shouldn't be ordering that test.”
He noted that in the state of Washington, where he is medical director of the department of labor and industries, workers' compensation costs went from $34 million a year to $19 million after the state instituted a prior authorization policy for advanced imaging costs of musculoskeletal problems. “Most of this was a sentinel effect of physicians not ordering imaging tests [they were previously ordering], not from denials,” he said.
“Doctors are the arbiters of medicine,” Dr. Franklin said. “I know patients can sometimes be demanding, but physicians have to be able to stand up to that.”
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