Discover more from PulmCCM
Perverse Incentives: Do You See What I See?
by Milton Packer MD
--From MedPage Today
I am severely near-sighted and have worn glasses for most of my entire life. With the onset of presbyopia, the sharpness of images disappeared regardless of distance. Add ongoing issues with retinal membranes, and I can barely see. I could benefit from retinal surgery, but have put it off.
A few months ago, I saw a new ophthalmologist, and after a short examination, he told me the good news: My eyes were no worse off than they had been. My prescription did not need to be changed.
I was ready to depart when the ophthalmologist surprised me. "You know, your lenses are very slightly cloudy. You will probably develop cataracts in the next 10 years or so." (All quotations are paraphrases of an actual conversation.)
I smiled. Cataracts were the least of my problems. There were many real reasons for my vision difficulties.
But I asked: "Do you think that cataracts are contributing to my current problems?"
He was confident in his response. "Not right now. But in a few years, who knows? They are only going to get worse. You will need cataract surgery eventually. You might as well as have it now."
I reminded him that I had put off having retinal surgery, which might actually benefit me. Why should I undergo surgery for an eye problem that I did not yet have?
"Well, it is really easy to do. In a decade from now, you will be older. And the risk will be much higher."
I agreed with him that I would be older a decade from now. But I couldn't imagine how his recommendation would help me. I said I wasn't interested.
I got up and was ready to leave. But he tried one more time. "You really should consider cataract surgery now. It would be easy to get insurance to pay for it".
This was really sad. I thought he was interested in my eye health. Actually, he was more interested in the opportunity I might provide to enhance his surgical revenues.
Recently, a 91-year-old relative had a serious intracerebral hemorrhage, but recovered miraculously. It is really hard for him to get around, but he always goes for an annual checkup. His stroke wasn't going to stop him from his routine.
During the visit, his physician told him that the office x-ray equipment wasn't working, and that he needed to return in 2 weeks for his routine annual chest x-ray (which was normal during his recent stroke). When I heard the story, I told him that the x-ray wasn't needed. He didn't need to make special arrangements to return to the office.
So he asked: "Why would a physician ask me to return for a test that I didn't need?"
Good question. Why do physicians check the serum cholesterol in women who have advanced ovarian cancer?
Too many physicians order tests and recommend procedures primarily because they can be paid to do them.
Many healthcare practices -- and entire health systems -- focus on generating revenues in every possible way. The goal is to eke out every dollar from every patient interaction. In many instances, it means encouraging patients to undergo tests and procedures that are not needed but will be reimbursed.
This obsession with revenues is destroying medicine.
It is making both patients and physicians miserable. It is the main driver of healthcare costs, and it is delivering suboptimal medical care.
If we don't change our system of incentives to put patients first, we will totally destroy any trust that the public has in our healthcare system.
My eyes are awful. But I ask you: do you see what I see?
Dr. Packer chairs the EMPEROR Executive Committee for trials of empagliflozin for the treatment of heart failure. He was previously the co-PI of the PARADIGM-HF trial and serves on the Steering Committee of the PARAGON-HF trial, but has no financial relationship with Novartis.