Tag Archives: tort reform

The Consequences of “Over-Testing”: Doc, Am I Glowing in the Dark?

In medicine today diagnostic testing and advanced imaging is readily available and widely utilized in most every clinical setting  Many physicians have given up the stethoscope and physical exam in favor of an echocardiogram and a CT scan.  Fear of “missing something” pervades every Emergency Department and has resulted in hundreds of thousands of unnecessary testing costing billions of dollars in healthcare expenditures.  Of course, the driving causes of increased testing and utilization of advanced imaging are numerous and complex.  Unfortunately, in my experience, the two most common reasons are fear of malpractice litigation and a desire for greater reimbursement.

How do we best determine when to test?

The most basic testing techniques rely on Bayesian statistics–the question to be answered must be well defined and then a clinician must determine a pre-test probability of the presence (or absence) of the disease in question.  The best utilization of a diagnostic test is when a clinician has an intermediate pre-test probability that a particular disease state is present.  If the pre-test probability is low, then there is no need to test.  If the pre-test probability is high, then the clinician should proceed with treatment rather than an additional testing step.  In the case of coronary artery disease, if you have a patient with multiple risk factors and symptoms that are a bit atypical, diagnostic testing with a stress test with imaging makes sense.  If you have a young person with no risk factors, and very atypical symptoms diagnostic testing does NOT.  In contrast, if you have a patient with classic angina, an abnormal EKG and multiple risk factors you may want to forgo diagnostic imaging and proceed directly to cardiac catheterization.

What are the risks associated with radiation?

In today’s New York Times, authors Redberg and Smith-Bindman argue that the over utilization of CT scans and other radiation based diagnostic testing results in a significant increased risk for certain types of cancers.  I tend to agree.  The radiation exposure associated with one CT scan is equivalent to more than 500 plain chest X-rays.  The FDA estimates that a patient’s lifetime risk of developing cancer from radiation exposure to a CT scan approaches 1 in 2000.  To place this all in perspective, the survivors of the atomic blasts in Japan were exposed to the equivalent radiation to two CT scans!  In addition to CT scans, nuclear medicine based stress testing in cardiology also exposes patients to large doses of radiation (even more than CT).  These tests are recommended at particular intervals by the American College of Cardiology in patients with known coronary artery disease (CAD) or in cases with suspected CAD with appropriate risk factors and baseline characteristics.  However, just as with CT scans, these imaging tests are often over-prescribed and overused.

What are the root causes for the over-use of diagnostic testing?

Much of the over testing seen in the US is due to fear of litigation.  Doctors, as a whole, want to do their very best for patients.  When the encounter a patient with a complaint that seems routine, many astute clinicians also think about more serious diagnoses when formulating a differential.  Anecdotes from colleagues where a particular serious diagnosis was “missed” can often lead to unnecessary testing.  Moreover, the trial lawyers and “ambulance chasers” are an ever present thought for many clinicians.  The fear of being sued for missing a lung tumor in an asymptomatic patient can also lead to more unnecessary and non indicated testing.  This phenomenon is yet another important reason that we must persue tort reform in the US today. Unfortunately, another reason for overuse of CT scanning and other types of imaging is profit.  Profit and finances have no place in the clinical evaluation of a patient–however, economic realities have blurred these lines considerably in the last decade.  There are some clinicians that put reimbursement ahead of patient welfare.  Abuses such as routine, non indicated imaging for cardiac patients has been declining.  New guidelines and more government and regulatory scrutiny into these types of exams seems to be having a positive effect on reducing unnecessary radiation exposures.

What can we do to advocate for ourselves and our patients?

As a patient, it is essential that you ask your clinician precisely why the test is being ordered and exactly what impact the result will have on your clinical management.  As physicians we must have very clear reasons (and well documented reasons) for ordering tests.  Tests should remain an adjunct to history and physical exam for the diagnosis of disease–not a replacement for clinical experience and expertise.

So, next time you order a test (or your doctor orders a test for you) make sure you take time to understand how the exam is going to impact your course of treatment–if you are at a fork in the road, the best test should determine whether you take the road to the right or the left…..If you and your doctor already know which way to go, the test may only be another chance to “glow in the dark…”

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How Can We Fix the $2.7 Trillion Dollar Medical Bill????

It is clear that healthcare in the US is more costly than in any other place in the world.  We spend 18% of the gross domestic product on healthcare and our outcomes are no different than those of other industrialized nations who spend less than half that amount.  How did we get here and what are we to do about it?

Recently, an article appeared in the New York Times that explored the increased costs of particular procedures in the US today.  In the Times piece, Elisabeth Rosenthal provides insight into possible reasons for the elevated cost and the ballooning trillion dollar healthcare deficit.  Certainly, insurers, hospital systems, industry and physicians all play a role in the high cost of care in the US.  In general, US healthcare systems tend to test more (and the tests are much more expensive here) and provide heroic care in the late stages of life (and this care may not have a real impact on longevity or quality of life).  Ms Rosenthal uses the colon cancer screening procedure known as colonoscopy as an example of a test that has widely variable cost.  Depending on where you get your test the price tag can vary by thousands of dollars–but in other countries it can cost as little as a few hundred dollars.

How does this happen?  

Ms Rosenthal certainly makes many good points in her article and gives us all pause–industry, hospitals, insurers and physicians all share some responsibility.  However, one important group that she does not mention as a contributor to the  escalating healthcare costs are the trial lawyers and the American Association for Justice (previously known as the  Association of Trial Lawyers of America)–you may can guess why the name change.

First and foremost, I believe the lack of tort reform and the highly litigenous environment that has been allowed to thrive in medicine in the US is a major contributor to escalating cost.  Physicians must often order more tests than necessary in order to avoid frivolous lawsuits and utlimately find themselves practicing “defensive medicine”.  Unfortunately for US citizens, most politicians are attorneys by profession and they tend to “look after their own.”  There has been little activity on tort reform–the trial lawyers are an incredibly powerful lobby.  Medical lawsuits have been allowed to continue unchecked and settlement amounts continue to rise to astronomical levels.  Many lawyers have made fortunes by “chasing ambulances”

Secondly, as physicians begin to see revenue fall and medicare/insurance reimbursement are cut, many turn to free standing surgical centers to increase revenue.  By owning the “facility” and treating the patient there instead of the hospital, the physician group is able to recoup a “facility fee “ that is normally collected by the hospital.  In addition, medicare billing (which often makes no sense whatsoever) will pay higher fees if the procedure is considered “outpatient” or is performed in an ambulatory surgical center.  In addition, academic institutions often are reimbursed at higher rates in order to offset the cost associated with training young doctors.  A more standardized approach to determining payments and reimbursements for procedures and tests must be put in place.  Medicare and CMS reform is essential to this process.  Currently the application of common sense appears to be quite absent from the government regulation and medicare payment determinations.  The system is full of waste and redundancy.  Although an entirely new “coding” system for medicare is due to be launched soon–I am certain that this new process will solve none of our current problems.

Our healthcare system is sick.  Until Washington stops playing politics and calls all parties to the table for talks of compromise, reform and action nothing will change.  The system cannot be fixed by only dealing with one component.  We must strive for tort reform so that physicians can do what is in the best interest of the patient rather than what must be done “in case” they are sued one day.  Politicians must stand up for the American people and stop being swayed by the trial lawyer lobby.  Standardized, equitable and sensible payment systems must be put in place so that the system is not abused by moving procedures from one location to another in order to receive higher payments.  This is a big job.  There is no easy fix.  But we must commit to finding a solution so that the US can continue to claim to have the best healthcare in the world.

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