Lisa Rosenbaum

How human nature drives up health costs

IMAGINE YOU are at a dinner party. The conversation turns to medical ailments. Joe says his orthopedist ordered an MRI on his sore back and reassured him that nothing terrible was wrong. Fred says that he also has a sore back, but his doctor told him that he didn’t need an MRI and recommended he take it easy. Fred says he will go see Joe’s orthopedist.

Last week’s recommendations by nine medical organizations to rein in medical testing by “choosing wisely’’ would help bring down the costs of health care. But is choosing wisely in our blood?

Consider the costs of treating back pain. Back pain is among the most common reasons people seek medical care in the United States, with some $86 billion in health care expenditures annually. Imaging studies, including MRIs, contribute significantly to these soaring costs. But data suggest that these costly tests don’t actually make much of a difference. One recent analysisreviewed outcomes among 1,804 patients who saw a doctor for back pain. At both one-month and one-year intervals, those who received imaging were no better off in terms of pain, quality of life, or general well-being than those who received no imaging.


Based on several studies with similar results, the American College of Physicians and American Pain Society have issued guidelines to help doctors manage back pain. In the absence of certain red flags, such as numbness or weakness, these guidelines recommend against routine imaging. Nevertheless, experts suggest that one to two thirds of imaging for back pain is not warranted. Why is it so tough to follow the guidelines?

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Physicians, of course, are partly responsible. Fear of litigation and other concerns undoubtedly contribute to unnecessary testing. But physicians must also deliver care that reassures and satisfies, or patients simply find another doctor. So do MRIs help?

Two studies aimed to answer this question. In the first one, published in 2008 in the American Journal of Neurorardiology, all patients with back pain received an MRI, but only half knew their results. Though there was no difference in objective measures of disability, the patients who did not know their results felt better, and reported more symptomatic improvement, than those in the know. In a similar study in 2001, published in the British Medical Journal, only one group received an imaging test, in this case a plain film of the spine; the imaging group reported worse pain, worse overall health, and ultimately consumed more resources than those without imaging. In both studies, most patients simply improved with time.

But there’s a catch: Even though imaging made people feel worse, when it came to rating the quality of their care, patients receiving imaging were uniformly more satisfied. This disconnect, between what we like, and what’s good for us, may prove to be a big deal for health care delivery.

As efforts to improve health care accelerate, quality, under the guise of “value,’’ is increasingly tied to patient satisfaction. Medicare, for instance, under a broad initiative known as Value-Based Purchasing, will soon base hospital reimbursement upon hospitals’ “performance.’’ Hospitals will be graded upon their adherence to evidence-based guidelines, as well as their success in enhancing “patients’ experiences of care.’’


Placing health care value in the eye of the beholder, however, may fail to improve quality and cut costs. Certain drivers of satisfaction, such as good communication, undoubtedly improve health outcomes. But non-clinical factors, such as patient amenities, may impact satisfaction more than the hospital’s track record in treating pneumonia or heart failure.

This is no surprise. Should we expect patients to appreciate practices known to improve health, like having blood drawn prior to receiving antibiotics, or glucose controlled post-operatively? Of course not. We appreciate the familiar: good food, prompt service, and friendly staff.

The danger of excessive focus upon satisfaction is that good health care is as much about preventing future harm as it is about treating current problems. But we’re not wired to appreciate the bad things that don’t happen. How can we celebrate the infection we never had? Or the surgery we avoided because we were willing to forgo an unneeded MRI?

We must choose wisely, but our delivery system must start to recognize where human nature may stand in the way. Although counter-intuitive, Fred’s better off if he sticks with the doctor who reassures with words alone.

Dr. Lisa Rosenbaum is a cardiology fellow at NYPH Weill Cornell and an editorial fellow at the New England Journal of Medicine.