The View From Your Sickbed

by Patrick Appel

A reader writes:

I am a pediatric emergency room physician. I want to second what the surgeon said in his comments about saving the system money. In most health care situations, there is absolutely NO incentive for physicians to do so, and in many instances there are incentives to waste/spend as much money as possible.

For example:  when a young teenager comes into the emergency department with chest pain, there is something like a 1 in 10,000 chance that the pain comes from a serious cause in the heart or the lungs.  In almost every case these rare serious causes can be ruled out by talking to the patient and their family and by examining the patient. In the vast majority of cases no tests or specialists are needed. The visit can be brief, reassurance can be offered to the patient and their family, and the bill should be around $200. However, there is nothing to prevent me from ordering a whole battery of tests in this situation, and I have seen other physicians and emergency departments do just that. 

EKG to rule out a heart attack, chest x-ray to look for pneumonia or a collapsed lung, chest CT scan to look for a pulmonary embolus, outpatient cardiac monitoring, referral to a cardiologist, lab work to look for infection or electrolyte abnormalities, etc., etc.  What started as a $200 visit is now closing in on $15,000. 

I can tell you from experience this happens every day in ER's around the country. Furthermore, if I order a lot of tests and give a lot of referrals to specialists, I make more money because I just made the visit more complicated and I bill based on how complicated the visit was, the hospital makes more money because they get to use all those expensive machines they invested in, and I generate business for my colleagues in cardiology. Often, the patients are happier with the "mega work-up" as well. There is absolutely no downside for me to ordering tons of unnecessary tests (the same is true for unnecessary and expensive medications). Rare exceptions to this are the best health care systems in the country (Kaiser, Mayo) that actually do give physicians feedback regarding their efficiency and outcomes. Not coincidentally, these systems spend less money per patient and deliver the best care in the country by pretty much any measure you can come up with.