Wednesday, August 15, 2012

Applying "The Cheesecake Factory" to Medical Care

The colloquy as to how to resolve issues regarding medical care in the United States continues.   A recent article by the talented writer Dr. Atul Gawande in the most recent issue of The New Yorker tries to draw a comparison between how well the Cheesecake Factory manages its bottom line with how poorly medical care is managed in comparison.  He is absolutely right!  But why is he right?

Doctors, for better or for worse, are not like the franchise-holders of the Cheesecake Factory.  They are not required to follow a particular "reproducible, appealing, and affordable" recipe.  Not only are we not required to,  we also have no commitment, financially or otherwise, to do so.  But, in certain respects, maybe we should.

All reputable specialty organizations (e.g. American College of Cardiology, American Society of Gastroenterology, American Cancer Society) issue guidelines based on a thorough analysis of data from multiple studies pertaining to the clinical problem at hand. These studies are all listed for the practitioner to review should he so wish.  Guidelines are then published for the management of issues such as, i.e. when to prescribe cholesterol-lowering drugs, when to order mammograms, who should get a stress test, etc.  These publications further provide the practicing physician with an evaluation of the "level of certainty" for each of the proposed recommended guidelines, based on these extensive reviews.

Of course no physician is required to follow these recommendations.  But maybe he should.  We physicians, like everyone else, are prisoners of our experience.  We anecdotally remember our successes and failures and often, inappropriately, rely on this thoroughly unscientific data.  I, for example, clearly remember recommending open-heart surgery for a patient who did not survive the procedure, and allowing future diagnostic decisions to be influenced by this exceedingly rare outcome.

I strongly believe that these guidelines should be followed - they are shown to be "reproducible, appealing, and affordable recipes (as per the Cheesecake Factory.)"  Medicare, and insurance companies are using, and will (and should) continue to use these expert guidelines in decisions regarding coverage.  Physicians recommending steps and procedures outside the published guidelines will have to persuade the payers to cover them, and will be asked to provide thorough data to support their views.

If a physician recommends a procedure or diagnostic test not considered indicated by published guidelines, he should, of course be permitted to do so.  But an insurance carrier or Medicare (in other words, we the public) should not be obligated to cover the cost.  The patient, should he wish to proceed, must also assume full financial responsibility.   (Perhaps there could be a separate insurance market for such instances!)

Following guidelines a la Cheesecake Factory can make sense and can help bring down the upward- spiraling medical expenditures.

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