>>Actually, the book wasn't about doctors trying to make excess money from doing unnecessary tests. It was about a frame of mind that's become part of the medical mindset and training that results in too much testing.

The biggest issue is time: in my day, we said that history is 80% of the diagnosis and the kudos prize was to set your differential diagnosis before ordering a single test. These days, workload is far greater and armies of physician assistants and nurse practitioners order barrages of tests because that's the policy and they know no better. For the physician there's no downside to an MRI ordered in their name because the patient had a slight headache after their bottle of Chateau Cardboard last night. The payers who otherwise might step in to incentivize parsimony, have a perverse disincentive, or use blunt instruments (like fee caps) that lock in delegation and higher overall cost . Facilities who do actually earn $ from barrages of tests (which physicians do not) exchange efficiency for capacity. Price rises follow the increased capital costs. The spiral continues.

Bill is right that the physician who historically has been an unusually smart dude or dudette, is well equipped to enforce efficiency. But there's too much demand, not enough time, patients who assess barrages of tests as a proxy for quality as we've seen right here on UT, and there are legions of ambulance chasers if you omit to order a serum rhubarb, so it's not a realistic expectation until society demonstrates change itself.

The other alarm is that as retirement age approaches for the last generation of physician that valued parsimony and didn't order or delegate ordering of every test , there's no easy path back. This is a recurring theme in healthcare: once physicians and nurses in particular cease the heroic vocational performance they once took for granted, it's almost impossible to restore once they get a taste for the normal good life expected and enshrined in legislation for everybody else. That's another reason why costs keep rising and every time care decisions are delegated with the expectation of reducing expensive medical personnel costs: in fact, the costs rise again.