Medical Costs: Do Demanding Patients Share Some of the Blame?

Everyone knows, or should know, that health care in the U.S. is very pricey; it is  more than twice the cost per capita in the next closest country, and three times or more in other countries, most with with better health care outcomes than we achieve.  Our health care system is built mostly on a fee-for-service model and many experts have attributed much of the reason for the high costs to the way U.S. physicians order tests, basically by the bushel.  Some argue that U.S. physicians order too many unneeded tests and procedures because of the fear of malpractice claims.  But, studies have shown it is mainly just habit and little thought to the cost consequences.  For example, several studies have shown that physicians order about 30% fewer laboratory tests when the test prices are posted on the ordering form (somewhere in my article archive, you will find an an article about that subject).  Anyway, a new study takes a little of the blame away from the physicians and puts it squarely on the shoulders of our patients.

The study was published in the medical policy journal, http:// and was summarized in a brief article in yesterday’s NYT.  The NYT article was entitied, “Working together on costs,” and written by Pauline Chen.  The actual study was entitled, “Focus groups highlight that many patients object to clinicians’ focusing on costs,” and was written by Sommers R and colleagues (Health Affairs 2013;32:338-46) and was conducted at the University of Michigan.  The investigators (the lead author is a law student!) analyzed the way focus groups handled various scenarios in which they had to weight costs in determining what laboratory tests to order to evaluate this or that set of signs and symptoms.

How good were the focus groups in figuring out what tests to order?

The results were, as one of the study investigators stated, “disheartening.”  In short, the “patients” in the study did not want costs to be a consideration in whether a physician ordered this or that test, or even no test.  For example, should a head MRI be ordered to evaluate a patient for headache, even if ordering the test was not the standard of care based on the patient’s signs and symptoms?  Guess what? The focus groups chose the expensive tests almost every time.  The focus group particiants seemed to feel that it was more or less a patient’s “right” to get what they perceived as the best test to sort out their hypothetical problem, even if the physician advised against getting the test.  The hypothetical patients did not think costs should enter into the equation and they did not seem to understand that even if an insurer pays for a test, it still costs, and in the end the patient (and everyone else) pays.

So, it would appear that a patient’s sense of entitlement to get whatever test he or she feels is the best possible way to sort out a problem, is driving a large share of the high costs of health care in the U.S.  This information still does not let docs off the hook.  We physicians don’t always think through what tests to order and how to take a step-wise approach.  That is, not getting every test we might need, at the get-go.  With respect to our “patient-doctors,”, the data just tell us that we need to be much more skillful in dealing with patients’ expectations; we need to find ways to persuade our patients that we know a thing or two about what tests to order (or not to order), and that consideration of costs vs. benefits, results in better health care in the end.  It will be a hard sell.  For example, just look at the ridiculous television advertising for a wide range of expensive drugs (often with a long list of potentially serious side-effects).  You know how it goes: “Ask your doctor if such and such is right for you.”  Everyone knows the old adage:  “the customer is always right.”  We physicians (and others who order medical tests) must remember that the customer is not always right.  We would do better by our patients to worry less about pleasing them and more about providing them with good care.  It can be a very difficult balancing act.

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