It’s a brave new world my friends! It’s not enough anymore to treat patients with the highest quality care of which we are capable. We need to be able to do more than simply diagnose medical conditions, effect major health improvements, and do these things in a very short time and with numerous other patients waiting to be seen. It’s simply not enough to be the best provider you can be.

Now we have to treat our patients with world-class skill and do it in the most cost-conscious way.

Not an easy pill to swallow.

It’s no secret that the United States has the most expensive healthcare system in the world. An interesting study from the Journal of the American Medical Association had some interesting findings based on 2016 data.¹ This study compared United States health care expenditures and outcomes with a bunch of other countries including the United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark. A short summary of the pertinent findings are listed here:

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The United States has the most expensive healthcare system in the world

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For a detailed discussion and other statistics, I point the interested reader to the references. The study’s authors concluded that the United States spent approximately twice as much as other countries on medical care, and these cost differences were largely due to pharmaceutical and administrative costs. Given that the U.S. spent so much more than the comparison countries, it’s unfortunate that many of our outcomes are actually worse than the other countries.

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Given that the U.S. spent so much more than the comparison countries, it’s unfortunate that many of our outcomes are actually worse than the other countries

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According to this study, it seems medical care simply costs more here than in other countries, despite similar or worse outcomes. This reminds me of the sticker shock I received when I moved to San Francisco from Phoenix when I started podiatric medical school. I recall everything was simply more expensive, from a gallon of milk to a gallon of gas, despite there being no discernable difference in product.

As much as I hate thinking about costs, it is time to consider ways to decrease medicine’s sticker price. This is obviously a very difficult state of affairs to change, considering its multifactorial nature. However, one way to begin might be for medical providers to become more conscious of the costs.

On a personal level, being cognizant of consumption is usually the first way to change spending behaviors. Consider controlling personal monetary spending or losing weight. The first advice to control these issues is always to become conscious of just how much is going in and out. But does this work for medical care?

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Being cognizant of consumption is the first way to change spending behaviors

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An interesting study by Nougon and colleagues out of Belgium is instructive.² These researchers followed nine emergency medicine resident physicians at a university hospital for six months. For the first two months, the physicians ordered labs and imaging studies as usual. During the next two months, the residents were required to order the same labs and imaging from a list that included prices. The price list was also displayed at all workstations and patient rooms. The final two months was a washout period, which was used to see if resident behavior remained changed from the initial period.

The results were telling. For a total of 3,758 patients registered in the ER, examination costs were significantly reduced: 10.73% reductions for laboratory costs and 33.66% decreased radiology costs. Being aware of the cost of a test reduced utilization.

Similarly, Hampers and colleagues found cost reductions in a pediatric ER in their prospective, non-blinded, controlled study of practicing physicians.³ This study had the same run-in-intervention-washout structure as Nougon’s study and found a 27% overall cost reduction. Posting price information for labs, imaging, and common hospital procedures appears to have increased physician awareness of the costs with subsequent significant reductions. Again, it appears being aware of the cost of a test changed physician ordering behavior (although it’s important to note these changes did not impact patient outcomes – a much more complex outcome to track).

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Posting price information for labs, imaging, and common hospital procedures appears to have increased physician awareness of the costs with subsequent significant reductions in utilization

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It’s interesting that neither of these studies attempted to explain the reasoning behind these improvements. This is understandable considering the complexity of human behavior and the choices we make. Changing ordering behaviors of physicians is unlikely to be monofactorial. However, it appears the first important step to creating this change in behavior by becoming aware of the costs. Clearly, becoming conscious of a deleterious action must be the first step in changing that action for the future. Perhaps American medicine needs an infusion of attention to costs as a simple first step to reducing our high expenditures in relation to other countries.