When Should a Procedure Not Be Done? (And Who Decides?) February 2, 2010

I listened to a weekend radio program a couple months ago that ran a two-part series on health care in the United States. There is no doubt that our health care system is incomprehensibly complex in many regards, from cost to quality, coverage, billing, documentation, procedure necessity, training, innovation, competition, and much more.  There were so many eye-opening insights in this program that those two hours probably represented some of my best-spent time (outside the hospital) in recent memory.

One of the many “aha” moments came when they talked about the dramatic variation in physician practice styles in a particular small geographic area, despite no difference in disease rates or severity. While there are many factors that combine to explain this phenomenon, one stuck out in my head – physician competition and the need to maintain a practice and earn a living.  An ophthalmologist was asked how bad a patient’s vision had to be before getting cataract surgery. He answered (only partly in jest) that it was dependent upon how many ophthalmologists were in town – if there were only one, surgery would be performed if the vision reached 20:200 (pretty poor vision); if there were two, it would be more like 20:80, and if there were three, it might be 20:40. While cataract surgery could arguably improve the quality of life in all of these patients (from a lot to a little), it struck me how much the threshold bar could move, based on non-patient factors, including the need for a physician to maintain his/her career. (more…)