85. Customers will, in effect, “self-deny” their own claims. A new metric for success is the “Negaclaim” — an unnecessary claim avoided. This isn’t about denying care. Just as energy consumers aren’t interested in kilowatt hours, individuals aren’t interested in health claims — they want health restored and diseases prevented.

Dr. Garrison Bliss, Founder of the Direct Primary Care movement

This is part of a series of essays on the Health Rosetta’s Principles.

There is an unspoken truth in healthcare: Doing nothing trumps doing something most of the time. Or as I heard during my internship: “Don’t just do something, stand there!” Real medicine is not a series of brilliant diagnoses and split second decision made during crises. Dr. House is not a paradigm to be admired, just a crotchety old man with a drug habit and an ego that prevents his patients from getting a timely diagnosis and a safe trip through the hospital without be intubated, biopsied, CPR’d and lectured to in a foreign language.

We now know that doing nothing generally beats doing something in most lab work, roughly 30% of CT scans, 50% of annual mammograms, 66% of annual PAP smears, breast and testicle self-exam, most tonsillectomies, most nasal septoplasties, antibiotics for respiratory infections, many orthopedic surgeries, many popular endoscopies and nearly all routine PSA screening. The vast majority of common reasons for visiting primary care physicians can be treated by the patient with “nonmedical” treatments like drinking more water, exercising more consistently, eating better and managing potentially addictive and damaging behaviors.

So who is likely to choose doing nothing? Not your doctor, whose income, ego and fame will be enhanced by doing something brilliant. Not your government, which is tied in knots by the largess of the existing “stakeholders” so that regulations simply do not adequately mitigate the failings of the medical care complex. Certainly not your insurance, which makes its money by maximizing the premium (they get to keep a percentage of it).

The thing I have learned in 35 plus years in healthcare as a primary care physician is that overutilization is NOT created by patients. Patients want the coolest newest test that they heard about on television because someone reached out to them over the airways to convince them that their symptoms would be resolved in a few days by a new drug or surgical miracle. Nobody wants a surgery that won’t help them and that will cost them months of pain and unnecessary expense. Nobody wants a drug with more side effects than benefits. Nobody demands a test that wasn’t sold to them by a doctor, a clever marketer or by Dr Oz (who is as far as I can tell is both).

If this is true, then why is it that doctors feel that they have no choice other than referring their patient for gastric bypass or for an imaging study that the patient doesn’t need? The barrier for most doctors is not the unreasonable demand by the patient. It is that the explanation for not doing the test or referral will take more time than is available and that they will not be able to undo the damage done by marketers without spending more time than they have available in their day. Doctors get paid to do all kinds of things, but sitting in a room with a patient hashing through a complicated question is hard work for minimal remuneration.

Patients want help with their symptoms, not a reason to play in the healthcare world. They want clear answers to simple questions. They want false claims debunked and they want to hear the word “miracle” when it means just that.

In my office, I have the luxury of working for my patients, not for their insurance companies. This gives me a perspective which may be hard for other doctors to understand. I can spend an hour with a worried patient who needs to walk and do their back exercises for weeks before we start ordering MRI scans and consults – and I can get their buy-in nearly all the time. This is because they know that I work exclusively for them and that I don’t get a cut of the action for things I order. The unfortunate corollary of this is the knowledge that I am largely free of the incentives that virtually all medical care providers must live with.

I also know that there are many thousands of other primary care providers and specialists who, at great sacrifice of time and money, spend this time communicating with their patients with the same results. This is an act of bravery in our healthcare system and it needs to be acknowledged and rewarded. Unfortunately, it is not the rule but an exception to a rule. When the practical truth is that you have 10-15 minutes to see, treat and document a patient visit there is no possibility that you can have this discussion successfully. It is a flaw in our medical care system, and an expensive and dangerous one.

A truly informed patient will opt for less danger, less invasion and less expense if that is offered by a credible source, whether that is a provider or an internet site. Credible unbiased sources are hard to hear above the din of drug advertising and websites promising miracle cures, but patients will look for them if they can find them. As experienced consumers, we are all used to checking out potential vendors by looking at their Yelp scores or their performance with testing by Consumer Reports or websites dedicated to consumers rather than sellers. When we buy cars, we will look at crash test results. When we go to hospitals, some of us look at LeapFrog data before we sign up for surgery. If we reach a place in which patients get to direct their own care, we might even see new and useful data sources (best price, best outcome information) appear. Insurance companies have had this data for decades and have kept it quiet. This could be very valuable to consumers of healthcare if the insurers could be convinced to part with it.

In the end, patients will save healthcare if it is to be saved. They will need to have some financial responsibility and something to gain by spending their money well, but they will take this on with the same competence that consumers have brought to every other marketplace they have entered. We just have to build a playing field that allows them to play.

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