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Focusing On What Is Easily Measured Is Not Likely To Achieve The Ultimate Goal In Health Care Or Business

There has been a bunch of press coverage over a study published in the Archives of Surgery under the title, Surgical Vampires and Rising Health Care Expenditures: Reducing the Cost of Daily Phlebotomy, that found that simply making physicians aware of how much blood-tests were costing their non-intensive care unit leads them to order fewer tests.

This is all well and good, as there are many reasons physicians might order tests that do not contribute to better outcomes for patients. Perhaps the physicians have a financial interest in more tests being ordered, for example, or perhaps they are ordering tests they themselves think worthless but are doing so to practice “defensive medicine” in case they are ever sued. Perhaps it is just mindless rote activity.

Nothing in this study, however, was designed to identify any such reasons. All we can say is that if you make a weekly announcement to remind doctors how much is being spent on blood tests by their nonintensive care unit, the doctors order fewer tests. Or at least they did for the duration of this study—quite possibly the effect would wear off with the passage of time.

The media response immediately assumed that ordering fewer blood tests is a good thing. U.S. News & World Report headlined an article, Unnecessary Blood Tests Plunge After Cost Reminders: Study, and Katherine Hobson, writing on The Wall Street Journal’s Health Blog, ran a piece titled Reducing Unnecessary Blood Test By Telling Doctors the Cost. Reuters headlined that Putting a Price on Blood Tests Can Save Money — Study.

But we don’t know if the lab tests that went unordered were necessary or not. We don’t know if failing to do them actually saved any money. It is entirely possible that doctors in the study felt intimidated into ordering fewer tests than they believed desirable.

If one patient went into atrial fibrillation and died because a test wasn’t done to make sure his electrolytes were in balance, then the tests weren’t unnecessary, and it wouldn’t take many patients winding up having heart attacks and going into intensive care, etc., for it to mean that the savings on labs didn’t actually save any money.

In fact, even the definition of saving money can be difficult to pin down. For example, avoiding a particular test might not be “necessary” and might “save money” in the sense that the patient may recover all on his own, without medical intervention. Yet if the test would have identified the illness sooner and medical intervention sped the healing process along, meaning that the patient would return to work four weeks sooner, then the cost to society of not doing the test includes both a month’s lost pay for the patient plus  the value added  the working patient would create for his employer.

We are focused on these medical studies because we are dealing with illness among friends and family. Yet it also strikes us that this temptation, to think that what is easily measured is most important, is endemic in business.

Think about a subject such as shrink. Many years ago, we wrote a piece titled Three Cheers For Shrink that focused on anti-shrink efforts being made in the floral department. The gist of the piece was that focusing on reducing the cost of shrink is typically counter-productive. One should focus on getting the best outcome by utilizing optimal operating procedures.

All too often today, we see one short term goal — reduce lab costs or reduce shrink in the floral department — and neglect the ultimate purpose of our activity — bringing about good health or increasing profitability at store level.

To focus on the means without any attention to the ends one hopes to achieve is bad for business and bad for public policy.

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