The discussion about healthcare costs in the US — reducing it, controlling it, getting it to the right places — focuses on big ticket items like cardiac catheterisation, end-of-life care, and transplants of all types. Since family doctors don't do transplants or cardiac caths, we avoid the glare of the cost spotlight, mostly.
I recently saw a patient with a sore throat. I didn't feel that the patient's symptoms or risks required a strep test. But it was too late, in the new ‘efficient’ system for primary care reengineering, the nurse did it before I got into the room and results were already in the chart.
We all understand that antibiotics for a strep throat do not shorten the course of the illness, and that the purpose of giving antibiotics is to prevent rheumatic fever and poststreptococcal glomerulonephritis (PSGN). Studies show that the adherence of patients to a 10-day course of penicillin is about 50%. Changes in serotypes, social and living conditions, and other factors have changed the epidemiology and the reality of rheumatic fever and PSGN. In the past 10 years, my state, with a population greater than Denmark, has had six cases of rheumatic fever. The trend cannot be traced to antibiotics.
The larger question is why should we be treating strep throats in Wisconsin at all in 2010? One could ask that same question in the rest of the US.
Our academic department runs a large network of practices. In a 12-month period, we had 435 000 patient visits and did 35 000 rapid strep tests. Multiplied by the cost per test, the result came to $1.4 million. That works out to one rapid strep test every 12 visits and about $3.80/visit. This cost is for a disease that occurs once out of 1 million citizens yearly. Assuming the rest of the US was to behave like we do as a Department, we are spending billions of dollars yearly for strep tests.
This $1.4 million could be seen as costs to patients and insurance plans or as revenues for our clinics. Most doctors, including us, are paid on the basis of what is called ‘production’ calculated through a complex billing formula developed in the last century by druidic health policy wonks working in Washington DC. More tests make more relative value units (a misnomer if there ever was one) and make me more money.
If we look at any number of ‘simple’ office lab tests with an evidence-based eye, we would likely find more billions to be saved. There is a butterfly effect at the most fundamental level of general practice that initiates the chaos of the system.
Lessons learned. First, we better sweep our own back porch before we sweep off someone else's. Second, don't link income to volume of anything except real and measurable quality. Third, any change, even in the little things, will require all of us to act together or it will collapse, as in, ‘Well Dr Smith always does a strep culture on me, why don't you?’ Finally, the medical-industrial complex is at work in every GP's office, not just the high-end hospitals. LOTS of people make money on unnecessary stuff — doctors, office testing companies, drug companies, and advertising agencies. To change that requires everyone taking a financial hit and America is not ready for that. Yet.
- © British Journal of General Practice, 2010.
