"Just Say No" Is Only Part of the Solution to Reducing Health Care Costs

David Leonhardt had a piece in the New York Times this week called “In Medicine, the Power of No,”  that focuses on reducing health care costs by scaling back our current “do everything possible” approach to care. “Deep down, Americans tend to believe that more care is better care,” he writes, “We recoil from efforts to restrict care.”

The era of managed care revealed a pretty clear picture of how Americans feel about forced limits on the care they can receive. More recently, Conservatives fomented panic with their attacks on health reform that focused on the looming threat of government rationing of care—including “death panels” and refusals for surgery and treatments based on cost alone. Leonhardt writes;

“From an economic perspective, health reform will fail if we can’t sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare’s long-term budget deficit will grow.

“So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. ‘Being able to say no,’ Dr. Alan Garber of Stanford says, ‘is the heart of the issue.’”

I agree that a sea-change is needed in how Americans view health care—but I think it would be a mistake to assume that health care costs are out of control because consumers are clamoring for more and more care and need to be reined in. 

To start, health consumers need to be enlightened about all the financial incentives—for doctors, medical centers, drug companies and device makers—that drive the type and amount of care they receive. Let’s start with medication: It’s not surprising that patients ask for a specific name-brand drug at more than 10% of office visits. After all, they are continually bombarded with direct-to-consumer ads for any number of expensive and seemingly miraculous new drugs. If they received unbiased information about the relative risks and benefits of these drugs—including information about alternatives to drug therapy, they might not need to be told “no” so often.

In a recent article called “Getting to ‘No’”  in the Archives of Internal Medicine, researchers looked at strategies primary care doctors use to deny patient requests for anti-depressants. Standardized patients (essentially actors) made 199 visits to primary care doctors, complaining of “feeling tired,” depressed and having either wrist pain or low back pain. The patients all requested Paxil. In 56% of the cases, the primary care doctor went ahead and prescribed it.

But in the 44% of cases where doctors did not prescribe anti-depressants, they used three strategies for “getting to no.” These included a “patient perspective approach,” which really means talking to the patient for a while about where they heard about the medication and why they thought it would help them. Some doctors discussed with patients the underlying factors that might be causing the sleepiness (insomnia) and depression and in a number of cases, the doctors recommended that the patient speak to a psychological counselor before resorting to drugs. They talked about side-effects and risks of drug therapy.

Other doctors took a “biomedically-based” approach to refusing the patient’s request for anti-depressants. These practitioners either prescribed a sleep aid or ordered tests to find out if the tiredness was related to a thyroid problem or anemia.

Finally, in a minority of visits (just 6%) doctors were straight-forward and just outright denied the patient’s request for anti-depressants.

The point of the study was really to find out which approach to “saying no” resulted in patients still being satisfied with their care. The winner was (not surprisingly) the approach that was the most patient-centered. “[P]atients are much more satisfied with physicians who act in a way that pays attention to the situation that is driving the request," Debora A. Paterniti, the lead author of the study and associate adjunct professor of internal medicine at the University of California, Davis, told  HealthDay.

Doctors say that they go along with patient requests for particular interventions--even if they don't agree it's the best approach--because they worry that patients will be dissatisfied with their care if they say "no."  But it’s hard for me to imagine that most patients come into a doctor’s office or emergency room specifically requesting batteries of diagnostic tests, complicated procedures or expensive implants and devices. How would they even know what to request?

In the vast majority of cases, we depend on doctors to help direct our care by laying out reasonable choices. That includes providing up-to-date information on potential risks and benefits that can be easily understood. If there are guidelines in place for treatment, we expect our doctors to use them to help decide the best line of treatment.  The problem is the way that many doctors discuss interventions: They provide figures that give misleading expectations about benefits (for example, patients are told that a drug lowers the risk of heart attack by 30%, vs. being told that 1,000 people would have to take this drug for 10 years to prevent one heart attack). They routinely downplay side-effects and they underestimate recovery time. Studies have shown that when patients are given clear, accurate information about risks and benefits of care, they often pick the less invasive ones.

Consumers also need to know about the financial incentives in place that affect the type of care they receive. My recent post on spinal surgery provides one glaring example of how economic concerns can drive over-treatment and potentially harm patients. How many patients think about the financial incentives their doctor might have for recommending a particular test or procedure? It’s unlikely we would be aware that he or she attended an industry-funded workshop last week that was designed to tout the latest cardiac stent or vertebral implant or heart medication. Or that one of those companies just paid for our doctor to extol the benefits of that device at a medical conference in San Juan. How can we choose to “say no” when we are still in the dark?

I believe that pundits are right when they say that Americans have to learn to scale back on medical care. But I don’t think it needs to be achieved in the same way it was during the days of managed health care—when it seemed that many of the treatment denials were made purely to save money, without consideration about quality of care. An increased focus on learning to communicate risk and benefit effectively and by ramping up the patient’s role in decision-making will be far more important in reducing health care costs than learning to “say no.”