The dilemma of internists: caught in a box with technology
By Harold C. Sox, FACP
This year's Annual Session brought to mind the memorable line from Dickens' "Tale of Two Cities": "It was the best of times and the worst of times." The meeting was the best of times because nearly 6,000 internists feasted on a dazzling array of programs led by the finest teachers of internal medicine. It was "the worst of times" for me because I had many glimpses of trouble ahead for our discipline.
In my conversations, I heard evidence that some of the essential values that define our profession are being eroded. Many internists told me that they "just don't have time" for activities that they have always held dear.
I heard about hospital teaching conferences being canceled due to lack of participation and increasingly sparse attendance at medical grand rounds. Long-standing faculty at community hospitals told me that they are not able to accept any medical students this year. And internists told me of colleagues who are eager to stop their inpatient practice as soon as their hospital hires a team of hospitalists.
As members of a profession, we are obliged to keep asking ourselves if we are headed in the right direction. Therefore, internal medicine's future as a profession will be a recurring theme in this column. This month, I want to focus on one reason why internists "don't have the time."
I spoke with some internists who said that they have had to expand their practices because of the low reimbursement offered by managed care plans. I left the meeting feeling that many internists are seeing more patients simply to sustain their income to meet the needs of their families and to continue earning reasonable compensation for services that are essential to the community.
Why do managed care organizations demand that we accept ever-smaller compensation? The quick answer is that health plans are trying to cut expenses to stay competitive and sustain the high profits that keep their shareholders happy. While there is truth in this explanation, it is a half-truth that demonizes an easy target without seeking deeper meaning.
High technology costs
The root cause is our country's determination to contain medical costs at a time when medical technology is becoming better, more pervasive and more costly. Think of health care costs as a rigid box that contains two compartments. One compartment is physician compensation and the other is the cost of medical technology. Since the box is rigid, one compartment can grow only if the other gets smaller.
This model is oversimplified because it neglects hospital care, compensation for other health professionals and a changing population, but it accounts for the most malleable components of health care costs. According to this model, if the cost of technology goes up, professional compensation must go down.
While medical technology is one of the great wonders of the 20th century, many technologies add more costs than they save. The term "cost-effectiveness" is a measure of trade-off between added costs and improved health care outcomes.
Coronary bypass surgery for left main coronary artery stenosis is an example of a technology that is "cost-effective" but not cost-saving. The added cost per extra year of healthy life is "reasonable," but the cost of the surgery exceeds any cost savings that results from reducing angina pectoris and myocardial infarction.
On the other hand, inhaled corticosteroids in asthma reduce net costs (because of fewer hospitalizations) and improve the quality of life. At this stage in human health, we have a great many "half-way technologies" that improve the quality of life and sometimes lengthen life, but many of these technologies are quite expensive and add net costs.
Are physicians trapped forever in a box with a compartment—the costs of technology—that will keep expanding at their expense? In the 1998 Eisele Lecture at Annual Session, David Eddy, MD, PhD, pointed out that offering an intervention to all individuals often means far fewer gains per dollar than if the intervention is targeted at the people at greatest risk. To prevent one hip fracture on an average-risk woman using a bisphosphonate costs at least 10 times as much as preventing a hip fracture in women who face the highest risk of a hip fracture.
Patients as partners
As Dr. Eddy pointed out, however, physicians who want to be selective in how they apply bisphosphonates must contend with patients who want their personal risk, however small it may be, to be smaller yet. When it comes to their own health decisions, these patients act as if there is an infinite amount of money allocated for health care.
Dr. Eddy suggested that physicians engage patients in a partnership in which patients accept responsibility for allocation policies that take account of the finite resources that are available for their health care. If physicians used what we know about targeting tests and treatments on patients who will benefit most, we could reduce or at least control expenditures for health technology.
My father, a general internist who practiced in the 1940s and 1950s, would often say to a patient with ulcer symptoms, "We could get an upper GI series now, but it would cost you $100. Why don't we try antacids first and do the upper GI only if your symptoms persist?" He and his patients worked as partners to keep their health care costs down and to improve their health. We need to get back to the trusting relationships of those times—and soon.
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