Cutting Back on Unnecessary Medical Tests and Procedures
http://thedianerehmshow.org/shows/2012-04-09/cutting-back-unnecessary-medical-tests-and-procedures
With healthcare costs in the United States ballooning, some are calling for restraint in the prescription of expensive medical tests like MRIs.
Doctors order and patients request many medical tests that add to expenses without improving care. A number of medical and consumer groups are now recommending doctors think twice before routinely prescribing some common medical tests such as stress tests for people with no symptoms of heart trouble, MRIs and CT scans in the early weeks of back pain, and routine colonscopies more than once a decade. Please join us for a discussion on the kinds of medical tests some say we can safely skip and why.
Guests
Dr. Ranit Mishori
associate professor of family medicine, Georgetown University School of Medicine.
Dr. Christine Cassel
chief executive officer, ABIM
Dr. Eric Topol
chief academic officer, Scripps Health; director, Scripps Translational Science Institute.
Shannon Brownlee
acting director, Health Policy Program, New America Foundation.
Program Highlights
Most of us get medical tests we don't need. That's a fact recognized by almost everyone in the health care field. Last week, some medical and consumer organizations
issued guidelines about tests we probably should skip.
Some Common, Unnecessary Tests
"Some of the tests that have been noted are things like CT scans or MRI scans of the head after an uncomplicated fainting spell without any other symptoms, an annual cardiac stress test for a person who has no sign of cardiac disease and no risk factors, or routine chest x-rays or EKGs as part of an annual physical or before outpatient surgery or minor surgery, and then a very common one is MRI of the spine within the first six weeks of the onset of lower back pain," Cassel said. Brownlee said unnecessary care is actually quite a large problem, with anywhere from 20 to 50 percent of all care delivered in the U.S. estimated to be unnecesasary care.
Some Tests Are Money-Generators
Some doctors are more likely to order certain tests more often than may be necessary because the tests are revenue generators. For instance, Dr. Mishori said he has seen patients who have visited a gastroenterologist who have told them they need a colonoscopy once every five years, when his own recommendation would be for the average patient with no other risk factors to undergo the procedure once every 10 years. Dr. Mishori also said, on the other hand, that he's encouraged by some societies of specialist doctors that have spoken out against over-testing and procedures.
"Life Is Pre-Death"
Dr. Mishori said one of the other problems is that doctors often treat patients and order extra tests for even "borderline" conditions. "So now, we're treating pre-diabetes, we're now treating pre-hypertension. We're now treating osteopenia. That's the pre-osteoporosis." Mishori said that "life is pre-death" and that doctors can choose to treat many things, but that they need to better evaluate which tests are really worth doing and which ones cause more harm than good.
You can read the full transcript here.
Comments
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Consider this. I was nearly killed in 1972 by a doctor who insisted that I wasn't sick. He would not ask for any tests. The doctor who finally treated me said that I had one of the worst cases of mononucleosis that had ever been seen anywhere. And that I would have died in a few days had treatment not been started. After this, I had frequent earaches that, again, doctors stated that I had no problem. Finally they stopped. Then off and on for the next 35 years I would have bouts of lightheadedness and dizziness that the doctors said were most likely stress-related. I had a number of tests, MRIs, and so forth. No results. Finally in 2009, a doctor suggested that I have caloric testing done for inner ear problems. The audiologist who did the test told me that my right inner ear was deficient; probably caused by an infection long ago. There is no known cure. I have to live with it. If I go back 35 years to an indifferent doctor who wouldn't even do necessary testing, do you think I would accept the idea of consumer groups deciding what is necessary and what isn't?
Your medical problem, Gary K, was a doctor who possibly did not do his/her job, not "consumer groups" and unnecessary medical tests. If you did not get relief, you should have sought medical advice from another doctor at the time. It's attitudes like this with patients demanding more and more things like antibiotics for viral infections (and MDs going along) or unnecessary tests or some drug they saw on TV, that contribute to the our problems with hyper-expensive and (crummy) medical care (as the doctor I work for who researches such issues always says, but with a stronger adjective).
batch: The ads on TV suggesting people ask their doctor for certain drugs and procedures certainly do not help. Doctors labor under both corporate protocols and artificially inflated customer demands. Practicing good medicine is almost impossible now.
Doctors know if they don't give every possible test and miss anything the patients will sue.
garyk's anecdote is exactly why we are in trouble. Humans generalize from anecdotes even when they shouldn't.
We have Gary saying "I didn't get a test, and that nearly killed me!" And so people think that more tests are better.
What we don't hear is all the people who did get a test that wasn't necessary. In fact, lots of people who get a false positive for a test and don't get sick from it (because, by definition, they never had it) will think it was the test that made them better.
Most other countries realize that there are limits as to just how much good we can do to someone. America will have to get there eventually, but I'm afraid it will only be after we have bankrupted ourselves and made ourselves a lot sicker with useless tests.
The big question is are these children in Tennessee, and other places, being cheated out of the education that allows them to compete in the modern world. I know many people who keep their strong faith, yet can compartmentalize and separate it from their knowledge of the scientific world. Children can, and do, learn how to successfully do this, and it is incumbent upon any school system to allow them to do so and not hinder their future opportunities.
I have overseen my parents healthcare for about three years. They are both 92 , vary feeble, and well insured. Unnecessary tests and treatment forthem have probably run into six figures. The biggest example is a vascular surgical group which has been paid at least 20000 and never performed any surgery, though the recommended my fathers leg amputation for gangrene and carotid artery surgery for my mother after a stroke. Every 6 months they runna battery offsets for the carotid. I have come to believe that our fee for service model with third party payers will doom our healthcare system and our economy. David, university park md
I recently got a bone spur playing tennis. The doctor had me go the the local hospital where he said he would be doing a nuclear scan. I said that's a pretty fancy bit of equipment. He said the hospital just got the unit and were encouraging doctors to use it.
I work in Hospital Revenue cycle management for several different hospitals in Texas. Regarding the point made that physicians in medical school should be made aware of how much tests cost- The # 1 insurance denial reason that created a loss for hospitals was lack of authorization for high cost radiology studies, not because they were not considered medically necessary or did not yield conclusive diagnosis but because the tests were not prior authorized by the insurance companies. For the most part this was traced back to the radiologists attempting to "Save" patient's money by performing less expensive studies that they assumed would yield the same types of definitive diagnosis. Doing this created a lack of authorization for the tests that was ordered and authorized. So in my opinion we need to focus med students on better documentation and patient care rather than "saving" money for patients.
Unnecessary medical testing is a multifactorial issue. But so far the discussion has missed the elephant in the room.
Many doctors are owners or partners in ownership of surgical centers, nuclear stress testing facilities, echocardiogram equipment, laboratory services, MRI facilities, etc. Studies have shown that patients of doctors who have these partnerships are more likely to receive these services.
Several years ago The Atlantic had an essay by a Harvard professor who examined why health costs were so incredibly high in McAllen, Texas, the poorest county in the United States. His findings: an astonishing amount of unnecessary tests, prescribed by doctors who had a financial interest in the hospitals where the excess tests were conducted--solely to boost doctors' profits.
Osteopeorosis begins young in my family; early 40's for my older sister and me, and late 30's for my younger sister. After my older sister was diagnosed, my younger sister and I had to fight hard to be tested because of our ages, in spite of the genetic issue. I share the concerns about over-testing, but there are cases where it is warranted and patients should not have to fight so hard.
I am a nurse midwife, and I wonder why wasn't ACOG (American College of Obstetricians and Gynecologist) at the table when developing guidelines?
These new guidelines are a wonderful first step in changing the culture in the country that “more” medical procedures, medicines, other treatments are better. Nurse midwives are legal in all states and are the guardians of normal birth for healthy women. The “evidence”* for 2 decades at least is that for similar women, the outcomes of nurse midwives overall are as good or better than those of obstetricians and family practice physicians (and MUCH less expensive). Yet nurse midwives are underutilized and under paid. For the same work as a physician, I get paid less by insurance companies and therefore by my employers. I have realized for years that this is not rational and this new situation that the medical societies have created is a real opportunity to look at obstetric practices. So, my question is, was ACOG (American College of Obstetricians and Gynecology) invited to participate? And, if so , why didn’t they?
* From ACNM (American College of Nurse Midwives) The Cochrane Collaboration produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. The Collaborative recommends midwifery led care for all pregnant women.
My doctor told me that I don't need a routine colonoscopy. I am 53 and everyone I know is recommended to get one. Is this becoming another unnecessary test if you have no family history of colon cancer/problems?
Thanks, Susan Levin
My doctor is already practicing this kind of medicine. Recently my blood pressure was up, he spent quite a bit of time with me, and after a few minutes I mentioned I stopped seeing my Shrink, he said go back. Shortly after returning to my monthly visits to the Shrink my blood pressure was back to normal. A few times he has said I could order this test, but I don't think it will show me much.
In today's medical environment, a diagnosis or potential diagnosis dictates a test or treatment. As noted by the panelists, to prevent over usage, a patient's medical history should be a deciding factor in determining whether a test or treatment should or should not be performed. This same approach must be taken by the insurance companies in claims processing. Tests deemed "not mandatory" in all cases, cannot and should not be denied or pre-authorized in all cases. A coordinated effort between the physician and insurance communities must occur for this concept to work.
I have MS. I am a healthcare advocate and know hat tests cost and I know that most Neurologists can get more information on where a patient has Neurological damage from simple neurological tests such as testing reflexes. I ask if MRIs are necessary and I am often told "NO".
While focusing on the cost containment in unnecessary testing it is also pertinent to remember and reconnect the patient/physician relationship. Alot of excess cost is related to the middle layers of managing healthcare which interferes with the one to one relationship so critical to excellent healthcare. Cheryl
I never heard anyone discuss family history. Maybe that is a given with a good physician. My doctor knows my family history, and I have up-dated him as I find new information as it has become available through family members or on line, i.e. death certificates.
Another problem I did not hear discussed was giving a clear explanation
of test results. My primary physician is very good about this, but some specialists don't do as good a job of getting information to him, even though I always ask the test results be sent to him.
Overall, however, I am pretty satisfied with the balance of preventive care and ocassional testing in my own health care.
There was a study a number of years ago, about why people sued their Doctors. It turned out that when a doctor or hospital apologized about the issue, lawsuits almost always went away. Hospitals and doctors are afraid to apologize because they are afraid of lawsuits, but it turns out it is the opposite.
My 66 year old sister spent the last seven years of her life in a nursing home after MS rendered her paraplegic and unable to care for herself. Because she was covered by Medicare (and a supplemental purchased by family) she was almost daily bombarded with visits from practitioners "cold-calling" on patients offering services and tests she neither requested or needed. Luckily we spent 6 days a week for 7 years at my sister's side to monitor her care. Purely by accident a bill was sent to us instead of the nursing home and we discovered a psychiatrist was billing Medicare for hours of service that he never rendered. When we brought this to the attention of the nursing home, they defended the psychiatrist and threatened us if we brought this matter any further. During a health crisis concerning my sister's failing kidneys, a "roaming" cardiologist whom we never consulted suggested an echo cardiogram which we knew was totally unnecessary. The nursing home medical director insisted that she undergo this test as long as she was going to be in the hospital for a cystoscopy. When we refused, he said he would deny permission for her cystoscopy. We relented. Of course the echo cardiogram found her heart healthy. Indeed, her heart was strong until the end of her life. Nursing home residents are generally forced by medical directors to endure endless numbers of unnecessary procedures on portable equipment operated by technicians hired by these unscrupulous Medicare thieves. And that's why end of life care has become prohibitively expensive. When my sister was dying, despite a living will and advanced directive, we again had to ensure that her wishes were carried out so that she was allowed to die.
kbatch, I did get a second opinion, but this wasn't a "leisurely" progressing disease. It was fast and vicious. Most people who have mononucleosis experience the symptoms of a bad cold. If you were a doctor, would you ignore symptoms of 105 degree degree, skin that had turned dark red over most of my body (from bleeding beneath the skin), and terrific internal pain. Taking time to do a search for another doctor wasn't an option. I had to be taken by ambulance to a hospital. Where the "unnecessary" blood test was done. If my parents hadn't taken the initiative, I wouldn't be sitting at the computer now.
You were right about the doctor, though. He was incompetent. Unfortunately, by taking the side of big insurance, you are just as wrong as can be. The reasons are obvious.
danweber, You obviously didn't understand what I wrote. I suggest you take a "reading" test.
Perhaps you have a vested interest in protecting "big insurance" and incompetent medical care????
Dr. Mishori says "Well, it's always scary because there's always the doubt that something might be cancer or life threatening ...but you try to rationalize your decisions and look at the evidence, look at what the patient is telling you, look at their symptoms, look at their physical examination. Yes, there's often a lot of uncertainty in medicine and that's certainly a point that drives some of this testing. But if you think rationally and you can talk it out with your colleagues, hopefully, most of the time, you won't have to face these cases."
and "I think it's a very minimal issue. That if things are well documented in the medical records about why a test wasn't ordered, that should preempt, you know, that the fact that something was thought about and why it wasn't done should preempt any concerns about a medical, legal consequence. So, no, I think that the main reason goes back to the techno-centric, ritualistic and ruminative aspects that we talked about earlier."
If only it were true that good documentation could protect against a lawsuit. It MAY protect against LOSING a lawsuit, but anybody who has been the target of a lawsuit will tell you that it's a horrible experience, even if you win it. It can take hundreds of hours away from productive work, and be extremely stressful on the doctor and her family.
So without very meaningful tort reform, there will STILL be plenty of cover-your-bottom tests ordered by physicians.