Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, December 09, 2009

Another Idea to Limit Unnecessary Testing

Defensive medicine, defined as "additional and often unnecessary tests to avoid lawsuits"(1), is widely acknowledged as one of the biggest factors in spiraling health care costs. The problem is more than just testing specifically to defend against potential litigation. At issue is what to do when patients request/demand inappropriate testing. This has been driven home to me at least three times just in the last week.

From patients with no family history of anything and perfectly normal blood tests (cholesterol panels, blood sugars) a year ago who "really want it done again" despite the USPTF recommendation of 3-5 year intervals for these screenings, to women who demand annual paps "just to make sure everything's okay in there," I find myself struggling to explain the downside of unnecessary testing. "But the insurance will pay for it," they respond. "What's the harm?" Sometimes I do it; sometimes I stand my ground; but the encounters often leave me drained and upset. How much is my inability to explain these things adequately, and how much is it the deeply ingrained American idea of "more is better," "better safe than sorry," and so on? There seems to be no way to tell.

So how about trying out this idea to reduce expenses from unnecessary testing:
Third party insurances will only pay for tests not designated as "medically indicated" by a physician if they are abnormal.
Although one might propose requiring a physician's version of a "certificate of necessity" (which we sort of already have; you can't get a test without a physician's order) whereby patients can get any test they want if they pay for it themselves, it looks really bad when that test comes back showing something unexpected. If insurance companies only pay for abnormal tests, patients have a little more skin in the game by taking on the risk of having to pay for negative tests. As most of them claim to only want the testing for "peace of mind," it stands to reason that many of them would also be willing to pay.

This is philosophically similar to the concept of "loser pays" litigation, although a more familiar and less arbitrary-seeming example would be the NFL rule for charging coaches a time-out for challenging penalties that are subsequently upheld. However you look at it, increasing the potential risk -- even only financial -- to patients demanding unnecessary testing, while not penalizing them for the occasional accidental finding, is at the very least a novel idea for controlling health care costs that I believe deserves serious consideration.

(1) Baker, Ninja; Malpractice Tort Reform; 1 December, 2009; policy paper for HS104a American Health Care, Professor Altman; Brandeis University; page 3 (comment from TA HKI: "good definition.")


At Wed Dec 09, 11:13:00 AM, Anonymous Anonymous said...

I've enjoyed reading the blog, but have to comment on this post. This past March I experienced sudden swelling in both injuries or pain. (I thought it was related to the exercise class I signed up for because I felt out of shape-short of breath). 3 doctors in my health plan brushed off my requests to find the cause-"deal with it" I was told. Finally was referred to a rheumatologist - I know I don't have arthritis but went anyway - and she heard a murmur and scheduled an echo. Results are Aortic Coarctation and Bicuspid Aortic Valve w/ moderate regurgitation.

At Wed Dec 09, 11:58:00 AM, Anonymous T4 said...

I can understand why you feel you have to comment. You might feel, well, somewhat unsatisfied with way your complaint were recognised (or rather not recognised) at first. However, please note that Dino focusses on tests 'just to be safe' in patients without any complaints, symptomes or other information that might justify a diagnostic test.

Well, your idea might work. However, as a non-American it seems to me you should try to 'delegislate' your healthcare (e.g. only law suits for *real* faults, no more CYA-medicine). By proposing even more rules for screening tests you might just in a way contribute to the whole problem. Why not improve the position of the physicians so they will be able to stand their ground? Not by making up new rules with the insurance companies, but rather by enabling the physicians. At least here in Europe we learn the adage 'do no further harm' and therefore: do no unnecessary tests. (Though, defensive medicine is become a problem here too.) Of course, my proposal is the hard way, it will require a complete cultural change.

At Wed Dec 09, 12:05:00 PM, Blogger #1 Dinosaur said...

@T4: yeah; right; de-legislate health care. Love to. As you say, though, that would require a complete cultural change. Good luck with that, eh. (Actually, I'm writing a book about it.)

At Wed Dec 09, 12:12:00 PM, Anonymous Anonymous said...

We have that procedure at our urgent care clinic for x-rays (a for-profit clinic that does VERY WELL while taking insurances). If it shows no break and was done on patient insistence, they pay.

It is GREAT for stopping the people who have the most minor trauma and want the X-ray because they already paid the visit co-pay, are already there, because their neighbor got one, etc.

The problem is that now, if I order an x-ray due to me (the doctor) wanting the film because I don't know whether or not there will be a fracture (not just because there is an obvious fracture that I want to evaluate), and it comes back normal, insurance tries to screw them into paying (at least one company). They basically pay only if there is a fracture...which, I guess, makes the x-ray useless as a diagnostic tool.

At Wed Dec 09, 01:27:00 PM, Anonymous Anonymous said...

Love your idea.

Furthermore, this would help patients who, like me, are NOT prone to requesting tests we don't need, because we're currently ALL paying for those tests via insurance premiums.

If I follow my physician's recommendations and have a pap smear every 3-5 years, but Lucy Low-risk insists upon annual pap smears, and Lucy and I both have Acme Insurance, *I* am subsidizing Lucy's paranoia. That is not okay with me.

At Wed Dec 09, 07:05:00 PM, Anonymous Anonymous said...

I practically cheered when I learned that I didn't have to have a yearly pap. What percentage of women want them (as opposed to having been scared into getting them or forced to get them for bcp for so long that they think it's still required)?

At Thu Dec 10, 02:35:00 AM, Anonymous Anonymous said...

It seems like a horrible position to be in - a gamble... take the test - if positive (bad news) you don't pay.
If negative (good news) you DO pay.

People of limited means may decide not to have necessary tests to avoid the risk of having to pay.

how sad.

I know I wouldn't take a test if I had to pay hundreds of dollars if the news is good. I'd probably use the money for food/clothes/college tuition/bills and wait for symptoms before I'd spend the money for a 'needless' test.

I'd hope I could take the test knowing the insurance would pay, regardless of the result. Otherwise, I would have to take my chances... maybe. what a choice to make!

Isn't it better (i.e. less expensive) to know early about possible problems?

At Thu Dec 10, 08:28:00 AM, Blogger DHS said...

[ ] I, the physician, certify that this test is justified by the evidence, and understand that if I cannot prove this, I may be required to pay for the test.
[ ] The patient requests this test and is willing to pay for it if not evidence-based.

At Fri Dec 11, 12:51:00 PM, Anonymous Diora said...

One thing you can do in reply to "what is the harm..." is to refer them to book of H Gilbert Welch "Should I be tested for cancer". Sure, the book is about screening of healthy people for cancer not other type of testing, but harms discussion in the book is applicable to all tests.

" women who demand annual paps "just to make sure everything's okay in there..."
And what about doctors who demand annual paps as a condition for BCP? This is unethical and borderline-illegal yet doctors feel it's OK to do it. I know you mentioned that you don't do it, but as obvious from posts on kevinmd, a lot of doctors do. I think if doctors expect patients not to demand tests, they should start by not forcing people to submit to screening throwing informed consent out the window.

At Sun Dec 13, 12:18:00 AM, Blogger paperhurts said...

Seeing as a pap smear is the only reason I found out I had pre-cancer cells on my cervix which needed to be removed, and a pap smear is - as far as I am aware - the only way to test for HPV, how on earth is having one done annually in any way a waste of resources/money?

At Sun Dec 13, 05:12:00 PM, Anonymous Diora said...

You don't understand overdiagnosis and overtreatment.

Just because you had pre-cancer cells doesn't mean the test saved your life or even prevented cancer in your case. The vast majority of these precancerous leisions never progress to cervical cancer and many low grade ones go away by themselves. Some of these (over)treated women lose fertility as a result. You can get some statistics here. Yet the cancer is very slow growing. Doing the test less often that once a year gives a chance for these leisions go away by themselves and reduces overtreatment. Since the progression from these "pre cancer cells" to cancer (when they progress) is meausured in years and even decades, doing the test less often reduces (a little) overtreatment and still provides the same benefits.

Another thing to keep in mind is that for every woman whose cancer is prevented by pap smears, over 50% of women have false positives, colposcopies and biopsies every year. And a lot more women are treated unnecessarily.

Doing the test less often reduces false positives and overdiagnosis a little, though doesn't eliminate it. So as with every screening test, there are benefits and risks - a small chance that you are going to be the one whose life is saved and a much larger chance of having a colposcopy, ambiguous result or bad effects from overtreatment. For this reason, screening should be a personal choice and not something doctors blackmail women into.

At Sun Dec 13, 05:48:00 PM, Anonymous Diora said...

Paperhurts - you may want to read this as well:
"For every 10000 women screened from 1976 to 1996, 1564 had abnormal cytology, 818 were investigated, and 543 had abnormal histology. One hundred and seventy six had persistent abnormality for two years or more. In the absence of screening 80 women would be expected to develop cancer of the cervix by 2011, of whom 25 would die. With screening 10 of these deaths would be avoided. Comparison of cumulative abnormality rates with numbers expected to develop cancer in the absence of screening suggests that at least 80% of high grade dyskaryosis and of high grade dysplasia would not progress to cancer. The lifetime risk of having abnormal cytology detected could be as high as 40% for women born since 1960."
Note the discrepacy between women with abnormal results and women who'd actually develop cancer. Also note that the mortality comparisons are screening vs absense of any screening not with less often screening.

This is just so that you understand your experience and also why individual "screening saved my life" reports are not the same as data.


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