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

David Leonhardt had a piece in the New York Times today 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.”

11 thoughts on ““Just Say No” Is Only Part of the Solution to Reducing Health Care Costs

  1. I think your points are right on. It leads, on one hand, to thinking more about the training physicians receive, especially in the areas of ethics and social skills, including the willingness and ability to listen. My son is in 3rd year of medical school and I could even in the first year how these skills are entirely neglected in favor of “the doctor always has to have THE answer approach.” I teach at a medical school myself so am working to move our approach in that direction of truly person-centered care. Lots of work to do in curriculum and culture reform as part of health care reform.

  2. The last option that they left out, but is going to happen most often is “the answer is no because of healthcare reform”. There is no reason for a provider to care if someone is satisfied with their 3rd party product. Which is partially a big reason why managed care failed. Blame will always be placed on the easiest villifiable faceless source and the actual cause. They missed the boat with chances for safeharbor with CER, and now there is zero enthusiasm to carry the water for the smooth rollout of such a thing.

  3. “But it’s hard for me to imagine that most patients come into a doctor’s office or emergency room SPECIFICALLY (emphasis added) requesting batteries of diagnostic tests, complicated procedures or expensive implants and devices. How would they even know what to request?”
    By adding the word “specifically” you have distorted what actually happens. In general patients don’t request specific tests or procedures, however there are many patients who want “the latest and greatest”, “everything possible done” and above all to have their complaints taken seriously – and what better way to take a complaint seriously in a limited time frame than to order a fancy, expensive test or treatment.
    “We have met the enemy and they are us”

  4. “We have met the enemy and they are us”
    Posted by: Legacy Flyer
    I like the tone of this post because I have always been a believer that the healthcare system dilemma in America can only be solved by a “top-down” approach. As Legacy implies, it is not patients who order tests and know when and where to do so properly, but the providers. That is “us” in his last statement. The providers must stop being “cats” and come together in agreement for standards of care so as to at least get a grip on runaway treatments and costs. It is the only acceptable way unless you believe overly charging unknowledgeable patients to squeeze them from getting all kinds of processes is a better way!

  5. Legacy,
    I agree that patients do not SPECIFICALLY ask for tests and treatments (that’s why I wrote “It’s hard for me to imagine”). I also agree that patients want to be taken seriously and to be assured that they are getting the best and most appropriate care. As such, rather than doing tests/interventions to keep patients satisfied, studies like the one I cited in my post show that a patient-centered conversation can also do the trick.
    If we do it right, the justification for “no” can be placed on evidence-based medicine–a somewhat more palatable “villain” than insurance companies or doctors. Americans have shown (in response to the latest mammography recommendations, for example) that they can be resistant to evidence-based medicine, but I think if doctors, advocacy organizations and health officials embrace them than the public will too.

  6. Before concerning ourselves with “too much care”, I suggest we get to providing care to all the folks who have postponed or had to cancel it over the past many years.
    Horse then cart.

  7. Patients do indeed request medications, and some may request surgeries, but let’s not place all the blame on them. Huge corporations make those fancy drugs and those sophisticated diagnostic equipment. Those corporations spend millions of dollars peddling their wares. The ads are so successful at creating medical paranoia that it’s amazing anyone could just say no. And no ads are ever presented discussing alternative methods for the treatment of anything.
    Our medical system is nothing more than a conglomeration of very huge corporations peddling their wares to an unsuspecting public. It’s a sophisticated form of snake oil salesmanship combined with downright quackery.

  8. bit of history in response to Jenga comments that patients will be denied care and told bill mandated it. when medicare introduced DRGs, which clearly accelerated trend toward shorter hospital stays, patients were regularly told by docs and hospitals that medicare required that they be discharged (not true, medicare paid a fixed amount for an average stay, acknowledging that some would be longer or shorter). ultimately, though, the drg system held and hospital stays continued to shrink while use of this blame-placing excuse appears to have abated

  9. There is the additional problem of saying “no”
    to a doctor. If you do this, you will shortly find yourself without a doctor even for a minor problem….

  10. Jim I don’t know what hospital you work in, but patients are told every day that they can leave or it is possible they could be charged. It hasn’t abated, it has only worsened. They are not told that they have to be discharged. They are only told they may have to pay if they stay longer and it is made very clear it is not the physician’s choice, it is about “meeting insurance criteria”. Which is defacto rationing. When care is rationed and the provider isn’t on board, you better believe the patient is going to know cause. We’ve listened to the current administration and progressive sites villify physicians for the past year and now they want to make nice, for a good PR when this rolls out. It simply doesn’t work that way. Any goodwill or chance of partnership (safeharbor for following CER guidelines for instance) is gone. That ship has sailed.