Dr. Dunlop lists the recent financial burdens placed on medicine, primarily by the federal government. Medicare and Medicaid still leave millions uninsured, communities pay for extra hospital beds, and federally funded medical schools have raised costs per graduate enormously. Additionally, malpractice insurance has imposed a large burden on physicians, as they must protect themselves against a society whose first impulse when wronged is to sue. And "an open ended financing system ... encourage[s] increase[ed] use of services," thus draining healthcare providers of finances.
Some blame lies with doctors themselves. Studies have shown that there is large variation in costs accrued for the same complaint between hospitals and even between physicians within a hospital. This implies two things: first, some doctors are charging much more than a service is worth, and imposing an unnecessary burden on financially stressed insurance companies, and second, that some doctors are practicing "careless medicine, imprecise thinking" by ordering "superfluous tests, unnecessary tests, [and] tests performed in an inappropriate sequence," which also raises the bill. Dunlop's solution to this problem is to make "physicians ... more sensitive to the economic consequences of their professional decisions," and he offers four methods for accomplishing this objective.
To illustrate how physicians misuse tests and incur huge costs for patients and their insurance companies, Dr. Dunlop gives examples from a national review board's findings. Doctors most often misuse tests on a "rule-out" basis, sometimes ignoring solid research showing that these tests either aren't as effective for ruling-out as believed, or that fewer will do the same job as more.
Dr. Dunlop describes the results of Chapter 372 in Massachusetts which offered incentives for hospitals that cut their spending. Hospitals did so successfully. If the legislation worked with hospital administrations, it should be enacted with physicians to hopefully achieve the same end. Physicians' incentives would be a fixed percentage of the total amount they saved the financing system, to reimburse them for the extra time and effort required to affect this cost reduction.
Dr. Dunlop places the burden of reducing healthcare costs partly on physicians themselves, encouraging them to help the efforts to make healthcare services more cost-effective.