Unnecessary tests drive up health care costs
BY DR. CHRISTOPHER LILLIS
Let’s say you have back pain. It’s been nagging for a couple of days, maybe a week. Over-the-counter medicines help a little but do not completely eliminate the pain. You can walk, but certain positions are really uncomfortable.
You’re pretty sure your back started hurting the day after you cleared the leaves from around your home. It’s time to ask your doctor for an MRI of your back, right?
If you are a patient of mine, you can go ahead and ask, but I am going to explain to you why getting that MRI will not help.
You see, everyone gets back pain now and again, but not all back pain is the same. Doctors are supposed to distinguish between uncomplicated back pain—the kind of pain you get from clearing the leaves—and back pain that has associated symptoms such as weakness in one leg, a loss of sensation in one leg or perhaps a loss of continence.
Ordering an MRI for back pain complicated by neurologic deficits is the right thing to do. Unfortunately, hundreds of thousands of unnecessary back MRIs are performed in the United States every year, costing hundreds of millions of dollars.
This is but one small example of one test that is needlessly ordered every day that does absolutely nothing to help the patient receiving the test, but sure costs a boatload of money.
Estimates from experts demonstrate that an entire third of all health care spending in our nation is on tests that do not help patients, on medicines that do not improve quality or quantity of life or on procedures of negligible value to health.
Our annual health care spending bill in this country is $2.7 trillion. A third of that is approaching $700 billion. As our politicians in Washington argue currently about how to reduce our deficit, doesn’t $700 billion sound like a nice number to have back?
WHY QUESTION TESTS?
Don’t take my word for it. Check out the American Board of Internal Medicine Foundation’s project called Choosing Wisely. Pick up the June 2012 Consumer Reports. We (doctors, patients, insurance companies, etc) are finally waking up to the fact that indiscriminate testing without a thought to how much it costs—in comparison to how much it will help—is breaking the bank.
There are examples of “routine” things that happen every day in every specialty: primary care doctors often order “routine” annual EKGs when they provide little, if any, value. On the flip side, an EKG taken in the case of chest pain can be life saving.
As another example, ordering a CT scan or MRI of the brain for any headache is completely unnecessary, yet hundreds of thousands of these tests are performed.
I could single out so many examples of tests and procedures in this column, but I don’t want all of my colleagues giving me ugly looks as I walk down the street.
The dirty little secret is that ordering tests and sometimes providing procedures of little value create profit—especially if a doctor decided to purchase a piece of equipment used to do the testing. The machine cost capital, and the person who sold the machine to the practice used language like “you need to order x number of tests for a return on your investment.”
I personally believe, however, that brazen profiteering in medicine (ordering tests purely to make money without a care about clinical information) is relatively rare. I think it’s much more likely tests are ordered because doctors want to be perceived as “doing something.”
When a patient comes to the office, perhaps there is an expectation “something” will be done: a test ordered, a procedure scheduled, a prescription written, etc. But I have found that often, doing “nothing” is the best course of action.
An explanation of symptoms—where they come from, when we can expect them to resolve and with what non-invasive/non-prescription solution—is, in fact, “doing something.” But that can take time. It takes very little time to just order a test or write a prescription.
I also know that some patients demand testing because they believe it is needed even if a physician tells them otherwise. I have lost a few patients this way since I take care to order only what is needed, and nothing more.
Lest you accuse me of rationing, there are safety-related reasons as well. All tests carry some risk. The radiation you are dosed with from an X ray or CT scan better be for a good reason. And what if the test finds something unexpected but completely inconsequential? You are now going to have three or four more tests just to reassure you of your health.
Then there’s the risk an invasive test causes an infection, or a useless prescription causes a side effect. Money isn’t everything—the health of my patient comes first.
There are questions you can ask:
- Do I really need this test or procedure?
- What are the downsides?
- Are there simpler, safer options?
- What happens if I do nothing?
- How much does it cost?
We need a better level of engagement of physicians in understanding costs. We need a better level of education among patients about what quality care looks like.
Together, we can all help shift our health care system to a more fiscally sustainable one if we order the right test, for the right patient and for the right reasons—never more and never less.
Dr. Christopher Lillis is an internist with Chancellor Internal Medicine in Fredericksburg. He can be reached at healthyliving@freelance star.com.