Physician, Regulate Yourself

If doctors won’t help fix the problems of health care, they shouldn’t be outraged when outsiders try to do it for them.

On Jan. 1, 2020, a new Medicare policy is scheduled to go into effect that will eventually require doctors to use a computer algorithm to vet imaging tests to determine “appropriateness.” If the tests, such as CT scans and M.R.I.s, do not meet certain “appropriate-use criteria,” Medicare may not reimburse the cost. Intended to reduce unnecessary imaging, the policy may penalize doctors who don’t comply by requiring them to get “prior authorization” before ordering imaging tests in the future — in other words, to follow another regulation.

Predictably, many doctors want the policy reversed or at least delayed so that they can come up with an alternative. They say that there is little evidence that the regulation will achieve its intended aim. They have concerns about how the computer algorithm will interact with existing electronic medical records. More generally, they complain of burdensome regulations, created largely without physician input, that doctors already must follow. The new policy, they say, is another intrusion on physicians’ decision-making authority — an authority gained over many years of difficult training.

These are all valid points, and yet after almost six years of delays — the law was passed in 2014 — doctors have not advanced an alternative solution. Meanwhile, billions of dollars continue to be spent every year on unnecessary imaging, creating not just financial waste but also real risks to patients, including excess radiation and false-positive diagnoses. If doctors can’t or won’t fix a problem that is almost universally acknowledged in our profession, should we act outraged or surprised when an outside agency tries to do it for us?

To be fair, medical specialty societies such as the American Board of Internal Medicine have published lists of imaging tests that are generally not beneficial to patients, including M.R.I.s for most lower back pain and stress tests when there are no signs of heart disease. Using these criteria, doctors on their own have been able to reduce the volume of imaging.

However, publishing lists will take us only so far. I once worked with a cardiologist who was ordering stress tests on 20-somethings to generate revenue. Asking doctors to voluntarily reduce imaging along the lines of what medical societies have proposed will do little to counteract that kind of excess.

The growth in the volume of imaging studies is partly a problem of society, driven by the aging of the population, new technology and the rise of chronic diseases. But it is also a problem of doctors’ making, driven by forces such as “defensive” medicine by doctors trying to avoid lawsuits, a reluctance on the part of doctors (and patients) to accept diagnostic uncertainty (thus leading to more tests) and simply poor clinical decisions. No one is better equipped to address these issues than doctors.

Instead of having a knee-jerk rejection of all regulations of the medical profession, doctors should design the regulations themselves, through organizations like the American Medical Association. But we have been unwilling to assume this responsibility, only to react with outrage and self-pity when onerous or ineffective regulations are forced on us.

This is hardly the first time doctors have behaved this way. Consider what happened after Medicare was created in 1965 as a social safety net for older Americans. Health care spending (and doctors’ salaries) quickly skyrocketed. Reports of waste and fraud were rampant, partly because the government virtually guaranteed payment for medical services.

To stem the rise in spending, lawmakers and insurers created managed care, a new health care financing model that included price controls, fixed payments and insurer review of the necessity of medical services. Doctors fought back (and are still fighting). “Passengers who insist on flying the plane are called hijackers,” Russell Roth, president of the American Medical Association, acidly remarked in 1976 about the law that ushered in managed care, without acknowledging that doctors had done little to rectify the problems that made managed care necessary in the first place.

Today, doctors continue to show little inclination to solve health care’s problems. Most of us are too busy with clinical work. As professionals, we are notoriously independent and don’t often feel comfortable organizing or cooperating to achieve common goals. Most physicians don’t want to engage in the politics and economics of health care. We went to medical school because we were fascinated with human physiology, not the body politic.

But if we are going to retain more of the independence we crave, we must become more active in addressing the problems of health care, some of which we have created ourselves. Doctors are already raising their voices on social media and other platforms on issues like gun control and immigration policy. We need to turn that critical focus on ourselves. If we don’t want to cede control to “hijackers,” we must be willing to fly the plane.

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