Human history is powered by human nature, from which there is no escape.  Indeed, we are what we are, and that is why history repeats itself.  Thus, socialism tends to deflate itself with time and then implode while capitalism—unless restrained by market forces—tends to inflate itself with time and then explode.  The explosion in health care cost that we are experiencing today is an example of the latter phenomenon.  We spend more on health care than any other developed country but we no longer boast the highest quality.

         Medical Excess—a euphemism for medical waste—has cycled into fashion and it will take a long time before it cycles out.  In our technology-dominated time, it has become unthinkable to diagnose and treat without first running tests.  Indeed, this test-before-you-diagnose-and-treat (TBDT) strategy has taken such a hold of society that we have come to equate the quality of care with the number and complexity of the tests performed.  “They have run every test in the book and still can’t find anything, which means that I must be okay,” says the trusting patient. 

         However, the TBDT strategy carries within it the seeds of dangerous harm and unaffordable waste.  Moreover, for medical-correctness reasons, discussing it remains painfully unpopular among physicians.  In order to explore the causes behind this TBDT strategy, one needs to don white gloves so as not to offend, with one’s crude truths, some of the specialties that often practice it.

         Let’s define Medical Excess as the wasteful use of resources unjustified by their cost/benefit ratios.  Presupposing that our loyalties should always be to our patients, the question that begs an answer is—why do we then continue to indulge in medical excess?  Because, as explained below, our system’s built in incentives and disincentives continue to move us in that direction. 

         First, when reimbursements pay more for testing than for thinking, it is natural that we would be driven to spend our thinking energies justifying more tests rather than thinking on how to solve difficult clinical problems.

         Second, when valuable services—such as patient education, compassionate reassurance, coordination of care, availability, telephone consultations, good charting, and researching complex problems— are not reimbursed at all, their non-recognition constitutes a strong disincentive against them.  Consequently, instead of taking the time to avert or solve a clinical problem by phone, the physician sends his patient to after care.  And instead of the doctor making himself more available to his distressed patients, he delegates all these poorly reimbursable services to his ancillary staff.  Invariably, such delegation increases cost at the expense of quality and efficiency.

         Third, when preventive medicine is devalued in favor of interventional medicine, there is more of the latter and less of the former—even though everyone agrees that prevention is far cheaper and more efficient.  Intervention begets heroes while prevention does not.  A doctor who saves a life by stenting an artery is more valued than the quietly competent physician who prevents a hundred heart attacks.  Such a dichotomy has driven interventional care to the forefront of medicine and has relegated preventive care to the back rows of the profession.

         Fourth, fragmentation of care is reimbursed at the expense of continuity of care.  A doctor who spends valuable time trying to solve a multifaceted problem is paid the same amount as when he refers that patient to several sub-specialists instead.  By the same token, the doctor who used to admit his office patients to the hospital was so often punished by the system that he now refers them to a hospitalist.  The hospitalist movement was primed by need, which arose when fewer and fewer doctors were willing to admit their patients because of the disincentives inherent in the system.  While continuity reduces patient’s visits to multiple sub-specialists and saves resources, fragmentation amplifies expenses and scatters resources.

         Fifth, the calling of medicine is being eroded by the swelling science of technology.  As reimbursements follow technical advances, the wise and seasoned clinician is being demoted in favor of the technologist, the specialist, in favor of the sub-specialist, and the thinker, in favor of the procedurist.  Consequently, the physicians who take care of the entire human being are being supplanted by those who are more disease than human being oriented.  This disease-oriented shift has caused the cost of providing care, under many situations, to become unaffordable.  Medical expenses are the leading causes of bankruptcies in the USA.

         Sixth, the rising cost of malpractice and the fear of litigation have provided disincentives against dedicated primary care.  For the doctor, it is far safer and much more cost effective to refer a patient out than to try to solve a difficult problem and, by so doing, risk a lawsuit.  This strategy of patient bumping is rampant and is far better reimbursed than the strategy of spending prolonged visit times with patients in order to protect them from fragmentation.

         Seventh, the excessive use of medications such as antibiotics, pain pills, decongestants, sedatives, etc. is well reimbursed by the patients themselves who demand treatments that are not scientifically sanctioned.  To convince them otherwise, the physician would have to spend more time educating and teaching them.  But, since such time is poorly reimbursed, the physician prefers to spend his time on better paying activities, letting those medication-seeking patients have whatever they wish.         

         Ultimately, we are what we are, driven by incentives and repelled by disincentives.  What our present medical crises has proven beyond doubt is that the calling of medicine does not provide us with incentives that can compete with those of financial reimbursements and heroic recognition.  As the late Dr. Mark Johnson once said, “We don’t get what we pay for; rather, what we pay for, we get.”  Put in other words, if we wish to reduce medical excess, we must redirect our incentives and disincentives so as to reimburse thinkers as well as we reimburse doers and to reimburse time as well as we reimburse technology.

         And finally, it is salutary to remind ourselves that time is limited while technology is not.  Whereas paying for time saves money and discourages excess, paying for tests, procedures, and unnecessary medicines drains resources and encourages excess.