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One of the major challenges facing today's clinicians is the rising cost of healthcare. Sports and exercise medicine clinicians can address these challenges by making a working diagnosis on clinical grounds and using investigations only selectively. They should also educate their patient about the limits to funding and be prepared to use time as a diagnostic aid.
As clinicians we face many challenges. Hippocrates challenged us to ‘primum non nocere’—first do no harm. Second, the challenge is to practise medicine in a scientific manner. This has evolved from anecdote and case studies to evidence-based medicine, where such evidence exists. The third and potentially most difficult challenge is to practise affordable medicine.
In the 1950s, when I was born, the limits to medicine were largely around what we could do. Now the limits are increasingly around what we can afford. This is a major challenge facing health systems in many countries and is fuelled by several factors: demand for health services will always exceed society's ability to pay. This is compounded by physicians feeling duty-bound to advocate for their own patients. Additionally, politicians realise that health is an emotionally sensitive issue and funding decisions are often made in response to pressure from special interest groups—this has been termed ‘planning by decibels’. The Herceptin (Roche Basle, Switzerland) debate in New Zealand is a good example of this.1 Herceptin is a high cost drug used in the treatment of breast cancer. Funding for this drug was granted to New Zealand women after a high-profile campaign by women's health advocates.
Health administration is a science which is in its relative youth. Secondary and tertiary care services chew up the majority of the health budget. These are hospital based and several decades ago hospitals were usually run by a triumvirate of a medical superintendent (a senior doctor with widespread respect) plus the hospital matron (a senior nurse with similar professional respect) and a hospital manager. In the last quarter century there has been an increasing application of management principles to running hospitals; as managers who were not clinicians made increasingly important decisions, the experienced clinicians felt increasingly sidelined. This was further exacerbated by the phenomenon of regionalisation—administrators are responsible for large geographic areas that include tens, sometimes hundreds, of hospitals. A response to this has been the development of the concept of clinical leadership, an attempt to win back the support of clinicians.2
What can we do about this situation? I believe that it requires a partnership between clinicians, funders and administrators and, most importantly, patients.
What can clinicians do? First, they can adapt their modus operandi for dealing with patients. As a general rule, primary care medicine is less expensive than secondary care medicine and primary care clinicians are good at using time as a diagnostic aid. Second, they tend to lead the way in making a working diagnosis on clinical grounds where possible and as far as is practicable and safe. Third, as a clinician, one should be selective in the use of investigations (eg, laboratory and radiology services).
For example, clinicians should be highly selective in the use of high-technology imaging as inappropriate use of modalities such as CT and MRI scanning can very quickly result in cost blowouts. These investigations should only be requested if the clinical question cannot be answered with less costly investigations such as plain radiographs or an ultrasound scan. Remember only to order an investigation if the result would change clinical management. This is often a delicate balancing act and the main aim is the exclusion of treatable pathology; the more serious the effect of the treatable pathology, the lower the threshold to invest in excluding such pathology. Pathologists and radiologists have a role in all of this. One innovation would be to inform clinicians about the cost of investigations, and a practical means of doing this is on the request form. In this way, the information will hit the clinician in the eye every time he or she orders such a test. Clinicians, for their part, should liaise with the relevant specialists to ensure that their requests are appropriate and cost-effective. They can also provide regular clinical review of their patients which, again, will provide reassurance to these patients. In addition, clinicians need regular education sessions regarding appropriate investigation pathways. Clinicians, particularly in North America, face the additional challenge of a medicolegally hostile environment. This can put further pressure on the system as the practice of ‘defensive medicine’ means the ordering of additional investigations which add extra costs.
Administrators and funders tend to have relatively blunt instruments at their disposal. They can apply a cap on services or procedures. Alternatively, they can request that all procedures or investigations—or at least expensive procedures or investigations—require prior approval. A third option would be only a single provider, although this must be done in a disinterested fashion and be thoroughly above-board. If it is done poorly, the fallout can be significant, for example, the experience of contracting a single provider for laboratory tests in Auckland recently.3 In this case, the single contracted provider struggled to get the appropriate infrastructure developed prior to the commencement date for their service. As a consequence, referring clinicians experienced major problems obtaining results. Subsequently, there were many frustrated clinicians and patients.
I believe that administrators and funders need to recognise that fiscally responsible clinicians are worth their weight in gold and reward them appropriately. Payment for procedures is often significantly greater than that for clinical evaluation and patient education regarding their condition and various treatment options. It is now time to redress that balance. Administrators should educate clinicians about the cost implications of their style of practice—this will require delicate interaction by experienced and respected clinicians who can engage their fellow clinicians in one-on-one feedback sessions based on data collected by the administrator and funder. Thus far, the administrators have responded with relatively blunt instruments, for example, costly investigations have required the filling out of application forms and preapproval. This tends to raise the threshold of ordering specific investigations by clinicians, but also induces some clinician resentment and, inevitably, there will be delays in approving funding and some truly urgent investigations may not be performed in a timely fashion. I believe it is time for more of the carrot and less of the stick.
The third interested party in all of this is the patient. Patients need to be brought into this discussion—the sooner the better. Clinicians can use time in the consultation to educate patients and point out that no test is perfect. Patients have often been exposed to ‘gee whiz’ stories in the media, and particularly in sports and exercise medicine they have the misguided impression that the most appropriate management for a premier league footballer is also necessary for them as a weekend warrior. In the professional sporting environment, an MRI scan may be ordered for a player with a hamstring strain to help clarify the prognosis and give a closer estimate of the number of games likely to be missed by that player. However, this MRI scan is funded by the professional franchise, not by the health system. We have all experienced the patient who says to us, I'd just like to have an MRI scan so I can be sure of what is going on. We have to take the opportunity as clinicians to explain that investigations usually provide only a small amount of the relevant information and that the majority comes from a detailed history and focused clinical examination. In my view the rationing of health services, as was attempted in Oregon,4 is both fair and reasonable provided everyone plays the game. Over time, clinicians and patients need to be further educated about the limited size of the medical cake and their often unreasonable request for an MRI scan for their mild knee injury may result in a cut in funding to other areas of the health service, for example, funding for child cancer treatment.
In summary, there are huge challenges facing clinicians and society in the 21st century. Sitting on our hands is no solution to the problem. Do not expect politicians to behave rationally in attempting to work through these issues.1 Historically, most politicians have responded to pressure groups where they think it is going to maintain their political career, and it is a rare politician who will look beyond this to the long-term interests of their country. If we are to move on from funding ‘squeaky wheels’, then some form of collaboration between clinicians, administrators and patients is required. Clinicians should not be afraid to step up and provide some leadership in this area. If he were alive in the 21st century, I rather suspect this is what Hippocrates would have wanted.
The case report below exemplifies the issues discussed above.
Recently I saw a US citizen in his 40s. He developed low back pain plus left sciatica following injury. His leg pain was severe and greatly exceeded his back pain. It was worse with flexion. He presented to me on referral from another practitioner and, despite treatment with non-steroidal anti-inflammatory drugs, his condition was not improving after 3 weeks of physiotherapy. There were no red flags in the history. Lumbar spine x-rays had previously been performed and were normal.
On examination, he had tenderness over the low lumbar region and a straight leg raise of 80° on the right and 30° on the left. He had a positive sciatic stretch test on the left and this was negative on the right. There was minor end range restriction of lumbar movements but no weakness was demonstrable. He had reduced sensation over the lateral aspect of the left shin and foot and his left ankle jerk was reduced. General examination was unremarkable.
I made a clinical diagnosis of left-sided S1 radiculopathy and informed him of the natural history of this. I gave him an information sheet regarding his condition and recommended he consider a lumbar epidural steroid injection. He was happy to have this intervention but wished, in addition, to have an MRI scan just to provide reassurance. He said that his insurance company would happily fund this. I explained to him that in New Zealand my usual clinical practice for patients in his position is to arrange an epidural steroid injection for people with lumbar radiculopathy and no contraindications or red flags. I routinely only investigate those people who have an atypical clinical picture or do not respond to an epidural steroid injection after 4–6 weeks. I would regard a positive response as 50% or greater improvement in the radicular leg pain.
In this instance, he heard me out but still wished to proceed with a request for MRI scanning. I dictated a letter to his referring practitioner and also to the specialist anaesthetist who routinely performs epidural steroid injections for my patients. I included the patient in the circulation list of this letter and explained in the letter that I did not think there was a clinical indication for the MRI scan but that if the insurance company were happy to fund a scan on this basis then that was their call. I then supplied him with a request form for an MRI scan of the lumbar spine. Costs of each approach are outlined below in US dollars:
As can be seen from the above worked example, the addition of high-tech imaging virtually doubles the cost of this patient's care without a demonstrable change in the likely clinical outcome.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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