Monday, November 12, 2012

Changing Medical Practice

In today's newsfeed from the Johns Hopkins Bloomberg School of Public Health there is a link to a blog entry about a study that asked medical care leaders why studies that seem to provide strong evidence of the relative effectiveness make such a small impact on the practice of medicine.  THe blog entry can be found here.

A key message from this blog entry seems to be--because the incentives don't point in the direction of adopting things that are less expensive.  The examples of studies with little impact tended to be things that would cost less money than the current approach to care.

We all hear from political leaders that we, in the United States, are spending too much on medical care.  We hear the same thing from business leaders.  We hear very similar things from insurance companies.  And, many individuals chime in with the same type of comment.

What we forget is two groups who aren't complaining--those who make the pharmaceutical products and devices on which we spend so much money and the physicians who prescribe their use.  Even with everyone else calling for reducing expenditures, the manufacturers do not have a strong incentive to save money.  The system right now pays in a way that bears at least some relationship to what is charged.  As such, companies that manufacture more expensive products that can be sold at a higher margin make more profits.

Physicians have only limited time to sort through the literature and to decide how to change their practice.  They listen to the way things are presented by manufacturers.  And they do not, at present, have to respond to incentives to provide care at a lower cost.

This is why I worry so much about the perspective of the cost-effectiveness or comparative effectiveness analyses.  The cost savings come from the societal perspective.  They may even characterize numerous other perspectives.  However, when all is said and done, if the economics don't work for the manufacturers and providers, change is unlikely to occur.  And, in a poor use of scarce resources, the manufacturer will spend money marketing (i.e., trying to convince people) that their products should continue to be used despite evidence to the contrary.

Unfortunately, that does not characterize an efficient system.  And changing the incentives in the first place may be much harder than changing practice patterns at any point.    

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