Doctors are the biggest driver of health care costs

There are many reasons to be dismayed by the error-filled and managerially incompetent rollout of the federal health insurance exchanges that are in many ways the linchpin of President Obama's Affordable Care Act. I sympathize with commentators who have called for the resignation of Department of Health and Human Services Secretary Kathleen Sebelius. It's hard to imagine Franklin Roosevelt not firing someone in his Cabinet had Social Security stumbled this badly out of the gate, or Lyndon Johnson not causing officials' heads to roll if the launch of Medicare and Medicaid had been so mangled.

Still, I believe that throwing the baby (the ACA) out with the bathwater (government officials) would be a huge mistake. Health care costs will continue to rise with or without the law's implementation, consuming an ever greater chunk of the struggling U.S. economy and causing government budgets to run into the red regardless of any future grand bargains on taxes and spending. The status quo stinks, and doing nothing is not an option.

Some of my physician colleagues have argued that the major problem in medicine today is that restrictive insurance companies and armies of utilization reviewers have curtailed our independence. Return decision-making power to doctors, they argue, and the system will run more efficiently. When surveyed recently about who had "major responsibility" to control health care costs, U.S. doctors called out trial lawyers, insurance companies, hospitals, drug and device manufacturers, and patients. Only one in three pointed the finger at themselves.

In an editorial in the New England Journal of Medicine, family physician Cheryl Bettigole takes the opposite point of view. Observing how a $20 to $30 Pap smear can be transformed into a battery of tests (some unnecessary) that cost hundreds or even a thousand dollars, she argues that physicians have the primary responsibility to protect patients from financial harm and be good stewards of health care resources:

So how do all these tests come to be ordered for healthy women who come in only for an annual gynecology exam? The answer is that someone ... checked off all those boxes on the order form. When I was in training, our attendings would ask a standard quiz question: “What is the biggest driver of health care costs in the hospital?” Answer: the physician's pen. A mouse or a keyboard, rather than a pen, now drives the spending, but we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.

Yes, the U.S. health care non-system provides physicians with numerous incentives to "do the wrong thing" in patient care. The more services we provide, the more money we make. Pharmaceutical representatives persuade us to prescribe expensive new brand-name drugs instead of more affordable (and often, more effective) generics. Indecipherable medical bills and insurance statements prevent patients from knowing how much their care costs until they've already received it. But these challenges should not be excuses for inaction on the part of practicing physicians or those in training. As Dr. Bettigole writes:

We need to teach medical students and residents to see [good financial stewardship] as an important aspect of their responsibility to their patients. Furthermore, we need to advocate for a system in which information about the cost and benefit of diagnostic tests is readily available to patients and providers at the point of care. If we fail to do so, we risk not only our patients' pocketbooks but also the gains we have made against cervical cancer and many other conditions. We contribute to spiraling health care costs and are doing real harm.