What patients need to know about the push model of health care.

Not long ago General Motors and Chrysler were bailed out by the US Government. They were in danger of going bankrupt, while Toyota had reached the status of the number one car manufacturer in the world. Why?  One major reason was a fundamentally different business model. GM and Chrysler ascribed to a batch processing model that saves labor, but requires the manufacturer to push the excess number of newly manufactured cars onto their customers. If GM built 5000 blue Chevrolets they used sales promotions and discounts to convince customers that they wanted and needed a blue Chevy. They created an artificial demand. When the economy was prospering this strategy generated remarkable profits; however, when the economy slowed this model failed. Toyota on the other hand has and continues to ascribe to a pull model. A customer orders a red Corolla. The order comes to the factory and a chassis and all other parts are manufactured just in time for that specific car. The company only makes the number of cars wanted and needed by its customers. In other words the cars are pulled by the demands of their customers.

You may ask how does this relate to health care? In certain regions of the United States, just like the American automotive industry, physicians have pushed care on their patients by performing unnecessary surgery, ordering unnecessary diagnostic tests, and requiring excessive visits to maximize income. For example the per capita cost of health care in Miami, Florida was $16, 351 in 2006, as compared to Salem, Oregon $5,877, and physicians in Miami were far more likely to recommend tests that were not clearly indicated and to schedule unnecessarily frequent office visits (see the Dartmouth Atlas  http://www.dartmouthatlas.org/).

These differences cannot simply be explained away by differences in the cost of living, demographics, or geographic distances. Comparisons of regions within single states and contiguous counties have also uncovered extreme differences in per capita spending on health care. In McAllen, Texas the per capita cost was second to Miami, $14,946, while in nearby El Paso the health care expenditure averaged $7, 504 per person.  This statistic is even more shocking when one discovers that the average household income in McAllen was only $12,000. The McAllen physicians were motivated by an entrepreneurial spirit, and were trained to perform specific procedures. They consistently recommended diagnostic tests or procedures for their patients disregarding the lack of evidence that these interventions were of benefit.   Both doctors and patients assumed that more care was better care. When asked about the high cost of medical care in McAllen, a local surgeon admitted there was “overutilization here, pure and simple”(A, Gwande, The Cost Conundrum. The New Yorker, 2009)

Analysts agree that a push business philosophy is likely to be one of the primary drivers causing the great variations in per capita health care spending in United States.  One of the tenets of capitalism has been “you get what you pay for”. However, patients as well as health care providers need to remember that when it comes to health care, under the present volume-oriented reimbursement system, higher cost health care often translates into more unnecessary procedures and tests. The more you do, the greater the likelihood of errors and complications. Analysis of regional health care quality and per capita spending have no positive correlation, in fact there may be a subtle negative correlation. In other words, higher cost health care may actually yield worse outcomes than less wasteful, lower cost care5.  One of the primary charges of the Hippocratic Oath is to “Do no harm”, and physicians enamored with procedures need to remember this charge (no pun intended) when the indications for a diagnostic or therapeutic procedure are equivocal.

Patients beware of over treatment. As a patient you need to ask, "Is this procedure indicated based on guidelines from your subspecialty society? Are there simpler less expensive and less invasive tests that could be performed first? We all need to understand that the push model of health care is driving up our health care costs, and has the potential to cause us bodily harm.