The Big Short and Inappropriate Eye Surgery

In The Big Short: Inside the Doomsday Machine, Michael Lewis insightfully dissected the reasons for our financial meltdown. He pinpointed the role of perverse incentives, illustrating his point with a healthcare story:

"Warren Buffett had an acerbic partner, Charlie Munger....If you wanted to predict how people would behave, Munger said, you only had to look at their incentives....Dr. Mike Burry agreed. [He believed] even in life or death situations, doctors, nurses, and patients all responded to bad incentives. In hospitals in which the reimbursement rates for appendectomies ran higher, for instance, the surgeons removed more appendixes. The evolution of eye surgery was another great example. In the 1990s, the ophthalmologists were building careers on performing cataract procedures. They take half an hour or less, and yet Medicare would reimburse them $1,700 a pop. In the late 1990s, Medicare slashed reimbursement levels to around $450 per procedure, and the incomes of the surgically minded ophthalmologists fell. Across America, ophthalmologists rediscovered an obscure and risky procedure called radial keratotomy, and there was a boom in surgery to correct small impairments of vision. The inadequately studied procedure was marketed as a cure for the suffering of contact lens wearers. 'In reality,' says Burry, 'the incentive was to maintain their high, often one-to-two-million-dollar incomes, and the justification followed. The industry rushed to come up with something less dangerous than radial keratotomy, and Lasik was eventually born.'"

Read a story in Chapter 7 in my book, about my own decision on elective surgery.

Seventeen doctors for shortness of breath: Unnecessary services

Dr. Sandeep Jauhar's story:
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his month-long stay he was seen by a hematologist, a endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a general surgeon, a thoracic surgeon and a pain specialist.

He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work up chronic anemia). When he was discharged, follow-up visits were scheduled with seven specialists.

Expert consultations had sprouted with little rhyme, reason or coordination.

Doctors are usually reimbursed for whatever they bill. Where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. The culture in practice is to grab patients and generate volume. Doctors are doing too much testing and too many procedures, often for the sake of business.

Advice: Ask, or have your patient advocate ask, about the value of an uncomfortable or painful procedure before it is performed.