People in the United States of America have long been used to getting what they want, when they want it. We do not like to wait six or eight months to see the doctor. We don't like to wait in line at the bank, grocery store, Disney World, or the movie theater. Even when on vacation, we tend to drive fast to get to where we are going. So it is perfectly understandable, if a bit laughable, to realize that we also tend to insist on antibiotics or an imaging study, such as a CT or MRI, when we visit the doctor with a complaint.

But here's the deal - as my knowledgeable colleague and orthopedic surgeon friend Howard Luks commented in his blog post - many people who present with an ailment do not necessarily need an imaging study to identify the root of the problem. What they need is a bit of faith in the doctor's ability to form an accurate diagnosis, and an understanding that a CT scan may help us see inside, but it doesn't tell us whether a perceived problem needs attention.

PPACA, aka Obamacare, is forcing hospitals to change the ball game. The dollar signs are undeniable. Hospitals are rapidly attempting to form Accountable Care Organizations and other such top-down entities that aim to control health care costs by controlling who gets paid for what. The difficulty, I see, is that some hospitals aim to control costs by controlling the providers.

Imagine the following possible scenario: Hospital X employs a general surgeon and other providers who may be necessary to care for a patient who presents with a sick gallbladder. Because the physicians and other caretakers are employed, any payment the hospital receives goes directly to the hospital, minus its expenses. The caretakers receive a salary, so any incentive they each have to control costs is eliminated. A patient complaint may be met with another CT scan or another lab test. The wait times may increase because a salaried professional has little or no incentive to "rush" to care for more people in the same time frame. 

What the above scenario does is carry the risk of lowest cost provider, regardless of quality provided. I'm not sure I'd like to visit that hospital if I were a patient, would you?

The problem with the above scenario, therefore, is that quality is trumped by cost-containment. In my opinion, higher quality helps lower costs because high quality health care includes high levels of expertise among providers who better recognize when a lab test or imaging study will make a difference in a person's care. Taking time to explain findings and diagnoses to patients and documenting findings and impressions in a patient's chart are additional important steps for the providers. The liability/defensive medicine argument is diminished or eliminated if proper communication has been accomplished. Patients do not typically feel slighted or ignored if their provider has discussed his/her impressions in a thoughtful, caring manner.

As I said before, a picture may be worth a thousand words, but sometimes all you need to hear is "you'll be fine."