Want better, cheaper health care? Cut back on medical tests

We Americans are still bickering over what’s wrong with our health-care system and how to fix it.

President Obama and Congress will try once again to hash out their differences in a bi-partisan meeting on February 25. I have my own prescriptions for our health-care problems, prescriptions inspired in part by a minor medical crisis in my family.

The crisis unfolded three years ago, when my son Mac, who was then 13 years old, mentioned during a routine checkup that he occasionally heard a weird buzzing noise. Mac’s paediatrician couldn’t find anything wrong with him, but she told me and my wife that tinnitus, or ringing in the ears, is sometimes caused by tumours on the auditory nerve. This possibility was highly unlikely, she assured us, but just to be sure, Mac should have an MRI, or magnetic-resonance-imaging, brain scan.

The radiologist who carried out the MRI thought Mac’s brain looked fine, but a tiny fuzzy spot in his inner ear could indicate auditory-nerve demyelination. This possibility was highly unlikely, he said, but just to be sure, Mac should see a neurologist. The neurologist said the MRI spot was insignificant, and his tests of Mac came up negative. The neurologist nonetheless recommended a second MRI, followed by another consultation with him and an inner-ear specialist. Just to be sure.

Then while I was driving Mac and two friends to a movie, he started talking about his medical odyssey, and his friends said they sometimes heard weird noises in their heads too. I called back the neurologist, and he said, yes, temporary tinnitus often arises for no discernable reason in teenagers, and usually it fades away harmlessly.

Now he tells us! To Mac’s relief, since the tinnitus had never bothered him that much, we canceled the next round of appointments. The university where I teach provides my family with excellent medical insurance, so our cost was a $20 co-payment for each visit-plus of course time and anxiety. On the other hand, all those tests and consultations easily cost thousands of dollars.

Excessive medical testing helps explain why US medicine costs so much and delivers so little. The US spends about 50 per cent more per capita on health care than the next highest-spending nation, Norway. And yet Americans rank 38th in life expectancy, just behind Cuba.

Conservatives in the US often hold up the National Health Service in England—which spends about half as much on health care per capita as the US does--as an example of the evils of socialized medicine. But a recent study in the Journal of the American Medical Association reported that Americans are more than twice as likely as Brits to suffer from such common ailments as hypertension, heart disease, diabetes, stroke and cancer.

Unnecessary tests can lead to unnecessary treatments, which can harm patients. Take the PSA blood test for prostate cancer. Last year a study of 182,000 men determined that for every one whose life was extended because of the PSA test, more than 40 received unnecessary treatments, notably surgery and irradiation, which can cause incontinence and impotence.

Mammograms for breast cancer pose similar problems. That is why last fall a task force of experts appointed by the Department of Health and Human Services recommended that women should begin receiving regular mammograms at age 50 rather than 40, the previous recommended age.

Over-testing stems from both greed and fear. Most American physicians are paid for the quantity rather than quality of their care, a model called “fee for service.” Doctors have a strong economic incentive to prescribe tests and treatments even when they may not be needed. Physicians also over-prescribe tests and treatments to protect themselves from malpractice suits.

So what are my prescriptions for ameliorating these problems? First, the fee-for-service model should be replaced with a different compensation scheme—perhaps one that gives physicians a flat salary with bonuses for improved patient outcomes.

The Mayo Clinic and other hospitals that have adopted this scheme deliver better care at lower cost. Second, malpractice laws should be revised so that doctors prescribe fewer “defensive” tests and treatments. Third, we need much more research on the efficacy of tests and treatments.

Barak Obama’s much-maligned health-care plan includes all three of these measures: reform of physicians’ compensation, reform of malpractice laws and research on efficacy of tests and treatments.

I hope the US Congress, which is still fiercely debating health-care reform, has the good sense to pass a plan with these three crucial measures. Otherwise Americans will continue to be stuck with the most inefficient health-care system in the world.

Oh, in case you were wondering, my son Mac no longer hears that funny buzzing sound.

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