Cost controls are necessary to successful health care reform. Unfortunately, it is hard to implement. As the Dartmouth study showed and Atul Gawande's article in the New Yorker
highlighted (and my previous blog explained), there are dramatic regional differences in Medicare spending. And more fascinating-the areas that spend the most have lower quality than the more pecuniary areas.

Also, neighboring cities and towns will have completely different patterns in usage (as the Atul Gawande article showed with McAllen and El Paso cities in Texas). How could towns just a few miles away be so different?

We've all experienced how "the other side of the tracks" can be wholly different in regards to race, income, real estate value, and education attainment. Clearly, cultural differences from township to township, city to city, and region to region have a huge effect on health care buying patterns.

Some of those cultural differences have to do with expectations. The more successful you are, the higher your expectations. I read a blog the other day (by a @ePatientDave) that brought to my attention a blog about the lack of good customer service in healthcare. I think we in medicine do have a long way to go to make life more convenient for patients (e.g. long waits in waiting room of offices could be twittered, emailed or texted to patients so they could do something else rather than sit and waste time). However, I had a blog about the Press-Ganey and how it is taking the decision-making away from physicians and not always for the better.

For those who don't instantly know about the Press-Ganey, it is a survey that administrators of hospitals use as gospel for who is the best hospital and is all about customer satisfaction. I do want my patients to be satisfied. However, if your definition of satisfaction is getting an x-ray for your ankle that you don't need, or an MRI you don't need, than you won't be satisfied even though I might be practicing excellent medicine.

In fact, on my Facebook account someone defriended me as a result of my comments that their MD practiced good medicine in resisting their insistence of antibiotics for bronchitis. They believed (as many do) that a Z-pack cures all, and their usage won't affect antibiotic resistance for the whole population (despite the whole micro/macro effects that each person has on public health...). The problem is, they were not uneducated demanding people. They were reasonable in wanting what they perceived as the fix to their problem, despite the fact that most evidence is to the contrary, and the negative effects are far worse than they realize. Clearly, changing their behavior will not be easy and will lead to very unsatisfied patients.

Therefore, when you talk about singlepayer and how well it works in other countries (which is debatable) realize there are extreme cultural differences in regards to expectations of care. The United States has a higher desire for personalization and as a whole will not be able to embrace reform that restricts their choice, creates longer waits, and forces their physician to refuse care that patients want but might not (statistically) need.

Thus, if we want to address cost-containment in medicine, you can't just blame the physician for over-testing and over-treating. Certainly, the current reimbursement system does allow for these abuses, and some MDs abuse this more than others (and in a previous blog, I outline my proposal to change that compensation system). However, many physicians don't have the energy, or the financial strength, to withstand the demands of their patients and give in to their demands. While tort reform could help physicians withstand their patients' insistence on unnecessary care, it won't solve the core issue: patients want what they want.

So how do you change patients' wants? Ask Frank Luntz, the master of verbal manipulation. I don't know the answer to that. My guess is that sociologists should have a large role in assessing these problems and would be better able to make suggestions as to how to modify the perceived needs of patients in a way that satisfies patients and does not enrage them.

The advertising complex is somewhat to blame for this as well, and might be the solution. It seems there is a disconnect in patient thinking: they want their doctor to practice good quality Evidence Based Medicine (EBM), but not when it conflicts with what they personally want. And it puts physicians in a bad position, "Give in to the patient, and practice expensive, less-than-ideal medicine or risk a lawsuit, patient-complaint, or administration sanction from low Press-Ganey patient satisfaction scores."

Maybe we can use the advertising complex with the help of sociologists to modify this disconnect. Maybe we can't. But if it is not done, I can predict that health care reform will to some degree make people unsatisfied bc costs will escalate out of control and need painful solutions to tamp it down, or face (on some level) the feeling of a lack of personal choice - especially in the areas of the country that have higher (and at times) unreasonable expectations of what their physician and what the healthcare system should provide.