HEALTH CARE has long been a stubborn hold-out against scrimping -- a strange, zero-gravity world in which inflation cruises along at triple the national average and even the well-off risk disappearing into a vortex of debt.
Finally, though, consumerism is coming to medicine. It is now possible to be an informed and vigilant patient. In bouts with hypochondria, defensive medicine, overpriced drug stores and overzealous practitioners, a little knowledge may pay off.
The easiest way to save on medical care, of course, is to avoid doctors. While not an ironclad rule, this can be better advice than you might think.
Pointless doctor visits are rife. Doctors acknowledge their uselessness in the face of the common cold, for example, and a host of other aches and ailments will respond to common-sense home remedies or go away by themselves. In fact, anywhere from 10 percent to 30 percent of doctor visits, medical tests, procedures and surgeries are believed by experts to be unnecessary.
Patients routinely turn up complaining of fatigue, constipation, gas, heartburn. Few need a blood test or a drug; instead they need to exercise and avoid cassoulet.
"You can spend a fortune doing a neurologic evaluation for insomnia and, more often than not, come up with nothing at all," says Dr. Gary Gitnick, chief of staff at UCLA Medical Center.
The problem, Gitnick suggests, is not simply procedure-happy doctors.
"Very often, patients tend to put physicians in a situation where the doctor feels he must prescribe, order a test, whatever, either because he's afraid of the medico-legal consequences or because he thinks the patient expects it," he says.
Even in the event of potentially more serious illnesses, waste is common. Take coronary angiograms, a popular method of examining blood vessels; 500,000 are done in the United States each year. Yet a Rand Corp. review of Medicare records recently suggested that nearly one in five are inappropriate.
Tonsillectomies and hysterectomies also appear to be widely overused.
"In most medical situations, there is not a need for a physician to treat every symptom and problem," says Gitnick, adding, "Many conditions don't require medical care."
Sooner or later, though, everyone develops a condition that really does need medical attention. When that happens, parsimonious patients are well-advised to respect a few simple rules.
Many of the following suggestions come from Charles B. Inlander, thorn in the side of organized medicine, co-author of six books on health care and president of the People's Medical Society, which bills itself as the country's largest consumer health advocacy group:
* Don't over-buy. If you don't need a specialist, don't use one. Start with a primary care physician -- say, an internist or family practitioner. Many patients see their cardiologist for everything -- and pay extra for doing so.
* Don't over-test. When a physician recommends a test, ask what he is looking for, whether other tests might be needed and how the information might be used. Gitnick suggests that patients keep copies of their test results to avoid repeat testing by different doctors.
* Get a second opinion before agreeing to any invasive procedure such as surgery, laparoscopy or even certain diagnostic procedures. Many insurance plans will pay for the second opinion, and patients often end up saving money.
* Negotiate. Ask for a doctor's fees before you sign on. Inlander goes so far as to suggest patients bargain with their doctors: "You can go in and say, 'I can only afford $25. Will you take it?' Most will say yes. They need your business.
"This is normal commerce we're talking about," he contends. "It's not anything highfalutin." Another factor in the cost of health care is where one gets it. Hospital-based care is the most expensive. Treatment in a hospital's outpatient department costs more than in a free-standing outpatient center, which costs more than care in a doctor's office.
So stay away from emergency rooms when you can make an office visit. Don't be afraid to use an ambulatory care center as a walk-in first aid station. But be cautious. Check in advance for licensing, accreditation, staff credentials, charges and volume.
A few tips on hospitals:
* Don't enter one on a Friday afternoon or a weekend, unless it's an emergency. Many hospitals, like other businesses, slow way down on weekends. Where possible, have blood tests, X-rays and other tests done in advance on an outpatient basis.
* Don't use inpatient services when outpatient ones are just as good. If a procedure can be done either way, choose outpatient. Not only is the cost lower but there is less risk of picking up an infection -- a common problem in many hospitals.
* Scrutinize your bill. Don't be afraid to challenge it. Look for duplication and phantom services. If possible, keep a log of medications and services received. Ask a friend or relative to be your advocate.
* Don't succumb to a medical procedure for reasons of vanity. Every procedure involves some risks. In weighing these against the benefits of procedures like liposuction and breast implants, you might end up saving more than money.
One of the easiest areas in which to save on health care is medication. Prescription drug costs are constantly on the rise.
Joe Graedon, a pharmacologist in Durham, N.C., author of two books on pharmaceuticals and a newspaper column, (it appears Tuesdays and Thursdays in The Evening Sun), suggests that patients get their doctors to give them free samples. That way they can look out for adverse reactions before forking out for a full prescription.