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Dr. Darrell White's Personal Blog

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Perverse Economic Incentives I: Ignoring Evidence-Based Medicine

Incontrovertible data does not always lead to the expected outcome. Take for example the much-trumpeted call for “evidence-based medicine”, choosing courses of action or care patterns that have been shown to be beneficial with regards to outcomes, reduced complications, or reduced cost when no benefit has been proven. The recent movement in which several national physician organizations have been asked to identify procedures or tests that should be eliminated for lack of proven efficacy is a presumed “no-brainer” way to reduce the cost of healthcare. In my eyecare world routine pre-admission testing for cataract surgery has been singled out as unnecessary, a waste of time and money for almost everyone involved. A New England Journal of Medicine article from 1990 is cited which unequivocally ¬†shows no benefit to the patient or the cataract surgeon. The data comes from the NEJM. From 1990. This is only a tiny bit removed in both historical context and gravitas from a couple of stones and a guy named Moses. Why are we even talking about this in 2013? Why isn’t this already a done deal?

Ah…there it is…”a waste of time and money for ALMOST everyone involved.” Some very powerful someone has an economic incentive that does not rest on either an outcome or on safety. Someone is getting paid for all of those EKG’s and blood tests for pre-admission testing prior to cataract surgery (I am a cataract surgeon; it isn’t us), ¬†and they have found a way to interpret various and sundry Medicare and OR accreditation documents in such a way that pre-op testing is mandatory. This blatantly ignores the evidence because the evidence ignores the economic incentives: a hospital is getting paid for pre-admission testing. All those patients are being robbed of their time, and every one of them who has an “abnormal” test result is then directed down the rabbit hole to chase a “cause”.

I know, I know…you’re shocked. SHOCKED! As bad as that example may be, and as perverse as it is that the champions of evidence-based medicine ignore the evidence when money is on the line, a story of a hospital doing something extra to get paid more is kinda boring; it just seems to happen all the time. In the private world of free-standing surgery centers that are not associated with a hospital pretty much everyone gets the joke about pre-admission testing and would do pretty much anything to be able to quit. You see, the private surgery centers don’t get paid the same way and pretty much lose money on pre-op testing. If they could get away with it they would all drop pre-admission testing for cataract surgery. The barrier is the economic incentive for the hospitals that own surgery centers and their influence on how regulations are interpreted.

In the face of data that provides a pathway to cost savings in healthcare, evidence-based medicine will only be utilized if the incentives are such that the invested players stand to gain, or if lights bright enough and cries loud enough arise to point out the perversity of the economics at hand.

 

 

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