Dr. Hanna Saadah - Scientific advances have made our medical world more complex and less affordable.  Before the scientific explosion took medicine by surprise, a good clinician could diagnose and treat most disorders while limiting expense and still managing to eke out a decent living.  Incentives were properly posited to save money because a clinician, who could get a patient well without overstretching the patient’s budget, was in more demand.  However, under the relentless scientific pressures of the past fifty years, incentives have been reversed, making medicine unaffordable for so many and rendering medical debts a common cause of bankruptcy.

In order to dilute the unaffordability of medical care and to allay the burdens of medical debt, insurance companies took the lead in becoming the major conductors of the health orchestras.  Although initially successful, the rising cost of insurance has made the premiums less affordable for more consumers and has caused the frequently rejected claims to become a major burden to those who can still afford insurance.  To maintain their robust solvency, insurance companies have developed an infinite number of stratagems designed to underpay for medicines, tests, and visits, leaving the patients saddled with large out-of-pocket expenses.  As things currently stand, the unaffordability of care is taxing the uninsured and the insured alike and that pattern is causing a global medical crisis.

Since the right-to-health-care is an unalienable right and since our consciences would never countenance the undue suffering that those who cannot afford health care are subjected to, it is our humane duty to find a reasonably affordable solution for the current crisis.  While experts are doing their best to temper this dilemma, medicine is facing a great shortage in primary care specialists, which is spiraling up the cost because patients are forced to seek multiple subspecialists for their multiple ailments.  Subspecialists tend to be disease-and-procedure oriented and therefore tend to consume more of the health money than primary care specialist who tend to be holistic, frugal, preventive, and available, thus providing a medical home for their patients.  A simple phone call to a primary care specialist may abort an emergency department visit or a subspecialist consultation.  An apprehensive young woman who calls her primary care specialist for acute chest pain and asks for a referral to a hospital or a cardiologist is told, after a few pointed questions, that she has shingles and is treated promptly with little cost.  Examples such as these abound in every primary care office, saving the patients unnecessary visits and costs.

One of the cost saving strategies little used these days is the Clinical Therapeutic Trial because it violates the current ethos of Investigate Before You Treat.  Thus, a patient presents with backache and, upon examination, is suspected of having a leaking disc.  One could immediately resort to an MRI, which costs several thousand dollars and is seldom useful, or else give a therapeutic trial with cortisone.  If the patient recovers, which is the usual outcome, an expensive and unnecessary test will have been averted.  Another patient presents with abdominal pain and is suspected of having diverticulitis.  A therapeutic trial with an antibiotic leads to recovery and the patient is not referred to a gastroenterologist for colonoscopy.  Examples of the cost effectiveness and potency of therapeutic trials are as infinite as the diseases and symptoms that provoke them.  So, why has the therapeutic trial fallen out of favor?

Those who have the knowledge and confidence to use therapeutic trials as their modus operandi have to be well-rounded primary care specialists who, after years of experience, have become highly seasoned, master clinicians.  Master clinicians are dying off and are not being replaced because we are producing more and more subspecialists, whose modus operandi is to Investigate Before You Treat and seldom resort to the therapeutic trial as a means of cutting cost and improving efficiency.  Consequently, too much of our health money is wasted on fruitless tests that carry more potential harm than benefit.  Things are being made even worse nowadays by hospitals who, by acquiring physicians, encourage spending and testing because it brings the hospitals more income.  Moreover, the primary care specialist is often punished—for spending the time needed to design and execute a therapeutic trial—by poorly reimbursing his cost-effective time.  It is short sighted to pay more for doing than for thinking.

This spiral of over-testing and over-doing will continue in its upward trend as long as the incentives are posited to encourage instead of discourage it.  A change in direction can only occur if doctors who are capable of saving money while still upholding quality are encouraged, rewarded, and valued.  For that awakening to occur, our current medical crisis may have to reach tsunami proportions.  Even though the US is ranked 37th in quality of health care by the World Health Organization and even though we spend three times more per caput than any other industrialized nation, we have so far been unsuccessful in rearranging our incentives to reverse this deadly trend.