By George Lundberg, MD
Just as “all politics is local”, so is all medical care personal. One patient; one physician; one moment; one decision. And in this era of balanced physician and patient autonomy, that decision often is an informed joint decision. Many patients now make serious efforts to learn about their conditions both before and after visits to their physicians. Many physicians welcome such informed patients and willingly discuss comparative effectiveness of the available diagnostic and therapeutic options. However, a frank discussion about the comparative costs and charges for the options, whether they be to the insurance company, Medicare, Medicaid or out-of-pocket for the patient, is usually missing.
Many health economists insist that the medical marketplace does not behave like other markets and believe it is fruitless to expect market principles to usefully inform the medical arena. That bias is true in emergencies,
operating rooms or intensive care units, and with patients who are mentally disabled.
Such behavior does not have to persist in an outpatient setting. In my book Severed Trust: Why American Medicine Hasn’t Been Fixed (Basic Books, 2000, paperback 2002), I presented the concept of “the economic informed consent.”
I believe that every patient who is mentally competent and in a non-emergency situation should be informed of the cost of a proposed diagnostic or therapeutic procedure or product, before it is “ordered.” This includes referral to another (often more specialized and costly) physician, no matter who pays the bill. The costs should all be discussed IN ADVANCE decision. This discussion should include whether it is worth it and
whether there a less expensive good alternative.
A recent NPR/KFF/HSPH survey reported that 55% of Americans believe that their insurance company should have to pay for an expensive treatment, even if has not been proven to be more effective than a less expensive
treatment. This attitude underlies the ruling convention, “if insurance will cover it, do it,” that lies at the root of our problem of health care cost inflation. No one is held accountable.
If we as a country could widely apply the “economic informed consent,” physicians and patients would become educated together. They could both become wiser shoppers for the most cost-effective diagnostic tests,
prescribed drugs, and specialists.
With an “economic informed consent,” physicians and patients can reset attitudes toward a healthy concern for the total costs or charges, stifling the usual knee-jerk response, “if the insurance covers it, do it.” No one
knows whether this approach, diligently applied, would actually cut down on wasteful spending, such as choices that drive huge geographic variations, but we do know that pricing an automobile, an airplane ticket, a dinner or a bottle of wine does affect consumer decisions. Why not try it for medical charges as well? Current sweeping proposals for health system reform all state that there must be “cost control” but offer little likelihood of delivering real cost savings.
Now is the time for the US Health Information Technology Initiative to create inter-operative systems that would provide the data to support widespread use of the “economic informed consent” in a timely fashion and
let the medical marketplace speak. Knowing the cost of a medical decision in advance should become a part of a new “Patient’s Bill of Rights”. In a medical care decision, it is the right of a patient to know “who pays whom
how much for what.” All of us in health care laud “transparency”–let that include economic transparency.
George D. Lundberg MD
President and Board Chair, www.lundberginstitute.org
On January 31, 2009 The Medscape Journal will be discontinued. One can only assume that the journal’s parent company, WebMD, could no longer justify the cost associated with a free, open-access, peer-reviewed medical journal that receives no income from advertisers or sponsors. The Medscape Journal’s budget has been supported by revenue generated from Medscape (the website), and their robust Continuing Medical Education (CME) business.
In these challenging economic times, American companies are taking a cold, hard look at their P and L spreadsheets and nixing the least profitable parts of their businesses. The inevitable “non-profit” casualties present an ethical dilemma. What will become of the noble pursuits that are based upon “doing the right thing” rather than making a profit?
There is no such thing as completely unbiased publishing (humans all have personal agendas – whether conscious or unconscious), though The Medscape Journal came about as close to it as any medical journal ever has. The journal is free to authors and readers, and provides 24-hour online access to both professional and lay viewers from around the globe. There are no advertisements or outside sponsors, peer reviewers work without compensation or specific recognition, and editors are paid a minimal salary (full disclosure: I know this because I was an editor for The Medscape Journal several years ago). CME credit is offered for articles determined to be of special relevance, but no articles are commissioned specifically for the purpose of CME.
The Medscape Journal is a wonderful experiment in high ethics. It espouses, in my opinion, the gold standard principles of medical publishing. Tragically, market forces (or perhaps the lack of perceived value by its own parent company) killed it. So what does this mean for medical publishing? If there is no economic model for “pure science” then are medical journals doomed to go the way of health media – promoting sensational or biased science for profit?
The answer is no. But we must tread very carefully now. The Medscape Journal is our proverbial canary in a publishing coal mine. Its inability to survive on ethics alone speaks to a growing lack of value placed on purity over profitability. We must soberly consider the facts: 1) The Internet creates the illusion that information is “free” and therefore subscription-based publishing platforms will end as viewers simply refuse to pay. 2) Advertisers are becoming more aggressive in their requirements – dynamic microsites and multi-media advertorials have replaced the old billboard approach, often blurring the lines between content and advertisement. 3) Search engines like Google are changing the way that health messages reach the public and scientists alike. The “impact factor” of research often lies in its marketing campaign. Important negative trials are buried under case reports, anecdotes, and news stories with snappier headlines.
So what are scientists to do? I suggest that those of us committed to science-based medicine join together in a united effort to harness new media tools for the public’s benefit. Let’s use social networking applications (blogs, Twitter, Facebook, online communities, etc.) to educate others about science, research, health claims, and potential biases. Let’s not be afraid of marketing scientific integrity – decades have already shown us how effective marketing can be for snake oil. If we don’t raise our collective voices – how will people get good information on the Internet? How will Google searches return highly ranked, sound information rather than sensational headlines?
Farewell to The Medscape Journal – and thank you for nearly a decade of honorable medical publishing. May the rest of us continue the vision, if only on different platforms.