Less Cost, Better Quality

JW was here. He was sent to me for complaints about his memory. His young - in his fifties. He was alcoholic and developed a case of severe esphageal varices which caused bleeding in the esophagus. He went to the ICU with some liver failure, and shortly after that (or maybe when he was in the hospital) he developed severe thinking problems. He lost all of his ambition and drive. He sat in the chair all day long. He couldn't concentrate. He was treated for a few months with anti-depressants. He did stop his drinking due to his near death experience. He just wasn't getting any better, so his physician sent him here to evaluate if maybe this wasn't just depression. His wife was at wits end. His sister was also at wits end. He had already checked an MRI of the brain (at their request mostly). I checked his EEG which showed severe slowing, so I told them that this was just not from depression since that doesn't cause severe slowing on the EEG. I told them that we had to look at several issues, but first I wanted him to stop his opiate medications including methadone and oxycodone which he was on. He had been on pain medication for years, so we were all skeptical that this was the cause of the severe thinking. In fact, even I was skeptical that this was the cause. Normally, I would have ordered a lot more testing. However, he didn't have medical insurance. I didn't think we should spend a few thousand dollars before making sure that this wasn't medication related. Every once in a while someone is on a medication for a long time and then the side effects suddenly turn up. It's unusual, but it happens. So we tapered him off pain medications. He came in a new man - he thinks like he used to. He is in a lot of pain, but his thinking is back. He wants to go back on pain medication because he is in so much pain. His wife wants him to stay off the pain medication because he is himself. I don't know what they'll end up doing.
This is an interesting case. I am often upset about all of the nonsense about better quality care for less money that is always talked about. I'm upset about it because it ignores all of the major realities that create such an expensive system. But this was done out of the necessity to save the patient's money. It was excellent care. It was very cheap. If he had insurance, it would have cost several thousand dollars more, and it would have taken a few weeks longer to find out what was wrong with him. I usually think that I'm pretty quick, but the need to cut costs in this case actually made me quicker. This is the first time that I feel like I improved quality by being driven to decrease cost. I'm not sure how much this goes on, but I can see that it is more than I have previously suspected.
For my practice, this pales to what I spend that I know doesn't really need to be spent to either 1) please the patients or 2) prevent being exposed to a law suit in the event of something extremely rare and unlikely. I suspect that's true for most practices. Still, I have definitely under-estimated the effects of trying to decrease costs as a factor in improved care. Now I will have to open my mind to this issue.