When Physicians' Financial Interests and Patient Care Collide

Physicians face a variety of "perverse" economic incentives that pit their financial self-interests against the well-being of their patients. And our current efforts at healthcare reform are not doing enough to fix these problems.

I recently overheard an orthopedist telling a patient who had a fibula fracture to use a cast boot and crutches (you only bear 7% of your body weight with that lower leg bone, so you can get around if you have to, but it hurts) or even stay in bed for 3-6 weeks when he (the orthopedist) learned he would not get a surgical fee. That is an example of a "perverse financial incentive." What do you expect? It's "human nature.”

Here are other examples:

• It's pure economics -- Doctors naturally will order more visits when paid by the visit, less tests when put at risk (eg, when they are "capitated" or prepaid), and they refer more (ie, 'dump' tough cases) to specialists when not at risk for those referrals. This incentive misalignment can affect your health. It will be made worse without payment reform as we are now seeing less primary care physicians (PCPs) and (who needs them?) more specialists on the front lines of medical care. (Locally, the primary care doctors who are left are getting older and, according to the American Academy of Family Physicians, only 31% of the nation's doctors are PCPs; since 1997, the number of medical students going into primary care has dropped 52%; the estimated shortage of family physicians will be 40K by 2020.)

• In the Senate, recently, several prominent House Democrats gave up the competitive priced-reducing, access enhancing insurance coverage "public option.” I don't know about you, but I hate too see serious reform reduced to politicians seeing what concessions they can extract for their vote. [See "Latest Public Option Concession Comes Into Focus"]

• Some insurers have the audacity to not pay for nebulizers or spacers, devices that are vital in the management of asthma in kids. Yet, these same insurers do not balk at paying lots more for the costly, discontinuous ER visit for the same treatment. (Perhaps, in the end, they're counting on your not fighting their denials, delays and dastardly deeds?)

• How about the doc who's too lazy or hurried to explain why not give antibiotics for colds, why not do the body CT scan, the complex spinal fusion for backache or the heart surgery that won't make them any better? (For instance, 70%-90% of cardiac angioplasties and bypass surgeries are unnecessary in stable patients with coronary artery disease.)

Not finally, we all know that Big Pharma's making our drugs the most expensive in the world; they're getting Congress to protect their trade as a quid pro quo for support and TV adds in favor of health care reform.

To be continued with next week's column...

Additional reading: "The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You about Heart Disease Prevention (But Probably Never Will)," by Michael D. Ozner, MD