Health-care providers need to become more cost-aware and efficient

I wonder what it would be like to be docteur in France.

In T.R. Reid's new book, "The Healing of America: A global quest for better, cheaper, and fairer health care," he looked at health-care delivery in France, Canada, the United Kingdom and Japan, among other countries.

I was struck by his description of France, where a detailed list of charges is posted on every waiting-room wall. In Japan, every office has a telephone directory-sized book, containing the government-allowed price for every treatment (shockingly low by U.S. standards — a brain MRI is $105).

I've been practicing primary care for the past 30 years, as well as doing part-time administration, reviewing requests for various treatments.We have no price transparency here — costs vary widely depending on who the payer is, where you live and who provides the care. The uninsured are billed much more for the same service than insurance companies are, due to negotiated discounts.

I can't help but think that all parties knowing the actual cost of the health care being dispensed is a vital missing ingredient in our national effort to rein in medical expenses.

During her annual checkup, my friend's gynecologist detected a faint heart murmur and recommended an echocardiogram (ultrasound) of her heart. Self-employed with a high-deductible health-insurance plan, my friend knew this would be an out-of-pocket expense. She asked how much it would cost; the gynecologist guessed "Oh, probably $400." Her calls revealed an actual cost of $1,000 (Getting this price required three telephone transfers to find the person who knew). When she called the physician to confirm the necessity of the test, he was shocked at the price.

"It's not that important," he said, before explaining what symptoms she should watch for as indications of something serious going on with her heart.

Like him, I normally don't have to think about the cost of what I order because patients so rarely ask. And if they did, unlike doctors in France, I have no "price list" on the wall. I wonder how often I'd tell my patients to skip or postpone tests of marginal value, if I knew the cost up front. Contrary to what patients might think, not every test I order is equally essential.

My friend later ruefully confessed that with a new job and low-deductible, employer-based insurance, she is not nearly as conscientious about cost.

The culture of medicine doesn't inculcate cost awareness. Physicians don't applaud colleagues for careful use of resources. On the contrary, in medical circles, being conservative about ordering tests or cautious with referrals is more likely to get you accused of working for the bogeyman HMO and "only caring about saving the insurance company money."

Of course, not ordering tests or procedures makes us worry that we'll be vulnerable to malpractice claims if there is an unexpected outcome. It always seems safer to order more, not less. Patients seldom thank me for not ordering a test; more often it makes them question my judgment and want a second opinion.

Residency training also instills a "search for the zebra" (the rare diagnosis) mentality. Physicians all recall an anecdote of the unusual and expensive test that identified a rare disease when it turned out to be correct (see the Fox network's "House, M.D."). We forget the other 99 times the expensive tests were negative. In my training, I don't recall a professor ever criticizing a resident for wasting money on unnecessary tests or drugs — only for not ordering something the professor thought should have been done.

When I deal with the current doctors-in-training, they seem as clueless about costs as the rest of us. I also worry sometimes that we do not think through what difference a given test result will make. If the patient isn't interested in surgery regardless of the findings, or there's no good treatment for the diagnosis, or the patient is a frail 84-year-old already doing poorly, how much should we investigate? But it goes against our academic training to leave stones unturned.

In my continuing medical-education conferences, we hear about the latest clinical advances in chemotherapy or MRIs but almost never does the PowerPoint presentation compare the cost of the new innovation to current treatments.

When I try to raise cost issues with my colleagues, most are uninterested; many are actively offended. I hear, "My job is just to take care of my patient the best I know how, whatever it takes" or "I have no idea what the price is" — all said without apology.

Patients with good coverage can care little about the actual cost, as long as someone else picks up almost all the bill. While most physicians might agree that "something" needs to be done about national health-care costs, this "something" better not lower our income, restrict our ability to order tests, do procedures or prescribe medication. So then how will we slow the growth of health-care spending? After Tuesday's Senate race in Massachusetts, President Obama apparently is willing to scale back the scope of the legislation, but he still insists we must have "some type of cost containment."

Many of us physicians act as if talking about the cost of a procedure or a drug is somehow beneath us. I am not sure where this "above the fray" attitude comes from, but the sad result is that being cost effective isn't considered an essential part of our jobs.

But it should be.

Sean O'Brien Stitham, M.D., is a physician living and working in Seattle.