quinta-feira, março 13, 2008

Many Doctors, Many Tests

No Rhyme or Reason
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist.
He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia).
Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.
This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.
Though accurate data is lacking, the overuse of services in health care probably cost hundreds of billions of dollars last year, out of the more than $2 trillion that Americans spent on health.
Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency.
And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest spending regions, the Medicare program alone could save about $40 billion a year.
Overutilization is driven by many factors“defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.
Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”
Consider medical imaging. According to a federal commission, from 1999 to 2004 the growth in the volume of imaging services per Medicare patient far outstripped the growth of all other physician services. In 2004, the cost of imaging services was close to $100 billion, or an average of roughly $350 per person in the United States.
Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.
“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both from a financial and a reputation standpoint.”
His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.
“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”
He shrugged and said, “That is what I have to do to break even.”
Last year, Congress approved steep reductions in Medicare payments for certain imaging services. Deeper cuts will almost certainly be forthcoming. This is good; unnecessary imaging is almost certainly taking place, leading to false-positive results, unnecessary invasive procedures, more complications and so on.
But the problem in medicine today is much larger than imaging. Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.
“The hospital is a great place to be when you are sick,” a hospital executive told me recently. “But I don’t want my mother in here five minutes longer than she needs to be.”
Dr. Sandeep Jauhar is a cardiologist on Long Island and the author of the new memoir “Intern: A Doctor’s Initiation.”

1. - Dr. Jauhar's comments are right on the money. I realized the same thing about testing. If I don't order an MRI, EMG, and other tests on every patient, they just go next door to another neurologist. My opinion does not matter - if all the tests are negative, I have not ordered enough tests. I saw a patient who came to me for a FIFTH opinion. She had 2 opinions for mini-strokes and 2 opinions for multiple sclerosis. I'm sure I won't be the last neurologist she sees.
— Neurologist, Houston, TX

2.- Dr. Jauhar makes some relevant and distressing observations about the state of our current medical system. However, he has told only part of the story and neglected to mention that reimbursement, led and championed by CMS, for all services, especially cognitive, every day office and hospital bedside encounters have been so drastically cut that no primary or specialty care physician can any longer cover the overhead practice costs - rent, office staff, malpractice, continuing medical education - much less make a living that permits the physician to payback school loans or take on additional personal debt such as a mortgage. I submit that positive adjustment of reimbursement to levels consistent with our legal brethren will result in dramatic change in practice behavior and less testing as Dr. Jauhar suggests.
— Seth Krauss, M.D., Anchorage, AK

3.- I am a physician practicing in Los Angeles, and there is no way to achieve real cost control unless you have a system like elsewhere in the world where there are real gatekeepers, and your testing is for real indications. Doctors, now have perverse incentives, whether to excessively test those with insurance, and to not test appropriately those without insurance so they go to the public system which is now breaking down. Those with insurance don't understand this because they don't pay their bills, I hope we can move to get some value in healthcare.
— Dr. von, Los Angeles

4. - I am a practicing general Pediatrician. None of the tests I order will bring me monetary reward. I agree fully with the main points of the article; it is timely and the point is well taken. But allow me to state that the two malpractice turmoils in my memory were related to tests not taken. In one case the patient was told to call back if not better. The parents didn't provide the feedback but in the final settlement this fact remained a mere footnote of no consequence. In the second case a test should have been done but wasn't. i am torn about this issue and see no easy solution.
Karl Berger. M.D.
— Karl Berger, Johnstown Pa.

5.- tests are ordered to prevent lawsuits, which our esteemed author neglects to mention. I refer to a case of a resident who did the right thing by not ordering a test after an informed discucussion with the patient. The result was a lawsuit against him and his residency program. He no longer practices medicine. When the system changes, then doctors will stop ordering tests.
— sybill, brooklyn

6.- I know I have been overly tested on numerous occasions. Basically if you end up in the ER--whether you elect to or you get coerced against your will, you're basically at the mercy of whoevers there. You can only hope that they won't order some expensive test to make a quick buck.
— Unamerican, CO

7.- I feel sorry for MD's. They are really in a no-win situation. I never thought I would say that, being an RN for 28 years. Patients take no personal responsibility for their own health. They eat cheeseburgers, drink too much alcohol, smoke, take a slew of unnecessary medications, never exercise are overweight and then go to the MD to "fix" all of the problems that they themselves have caused. And if the MD doesn't fix it, well, they will just sue. That is the state of medical care in this era. That is why so many tests are ordered. Here is some good advice for a healthier America: Eat right, exercise more often, don't smoke, take a vitamin, drink water, manage your hypertension and get some sleep. Sounds simple, but it really works and guess what? It is free. Not only would it make us healthier, it would help to drive down the spiraling costs of healthcare. Personal responsibility is the answer.
— Janice47, Boston, MA

8.- Totally agree w/ article. Reminds me of my training days in internal medicine - the mega work up, the "hyperconsultosis" - even if internists know what to do, they still have to consult - it is expected. Is a pulmonologist really needed for an uncomplicated case of community acquired pneumonia that is responding to IV antibiotics? How about chest pain which is clearly not cardiac in origin - do you still need to see a cardiologist? Physicians are paid for doing (not thinking). It is unfortunate - as the population ages, we need good, solid internists, but the US system (and patients) devalue them. That's why I subspecialized and became a cardiologist.
— rp, nj

9.- I am a also doctor and totally agree. But when I'm also a patient, I deplore the overspecialization that leads to delays and errors that derive from a "if I'm a hammer, then everything looks like a nail" thinking. I long for a GP or primary care physician who will coordinate my care, and I think others feel the same. Belly pain? The gynecologist things ovary, the GI doctor things bowel, the urologist thinks kidney or bladder...and soon you've had a zillion tests costly in terms of time, money, discomfort and anxiety, and MAYBE you'll have an answer. Headache? Is it brain, blood vessels, eyes, TMJ, anxiety? And so on...

We doctors no longer make megabucks. (Nor should we...) Many order tests to protect themselves. Many order tests "just to make sure." Some order tests when they have no idea what the problem is and hope a test will reveal something that will point them in the right direction. We do care about our patients, very much, but we care about our safety as well. We have to. I don't know what the solution is. I'm glad I'm not just starting out...
— Ellen T, New York City

10. - No. The opposite occurred. HMO medicine pressures doctors into making the quickest, cheapest diagnosis they can "sell" and medicate, then move on to the next patient. I lost five years of my personal and professional life to a missed diagnosis: I struggled to rehabilitate myself from an undiagnosed stroke while dealing with debilitating side effects of too much and too many psychiatric medications. Failure to test for and rule out underlying physical causes of psychological problems is inexcusable.
— Llyn, WI

11.- You've got to be kidding me. This has to be written by someone in the insurance company pockets. The way the system is now, you have to go to a doctor three times to get anything tested these days. No one wants to test for anything unless they absolutely have to because doctors are so worried about the bottom line and insurance company hassles. The only people rewarded are retired folks like myself and hypochondriacs. It took three trips to the doctor before my granddaughter could get a chest xray that found TB that could have killed her. How many people got exposed because no one wanted to pay for the test? I'd like the writer to compute how much money would be saved if we did more tests - you know, like preventative medicine. God forbid that doctors could help people from getting sick in the future rather than just treating terminal cases. Insurance companies have seriously wounded the healthcare system, and articles like these only show that there are more and more doctors out there who really should have taken up careers in accounting.
— Penelope, VT

12. - The problem with too many tests and doctor's visits is that the patient has no idea that too many are being done until it is too late to do anything about it. It doesn't help that medical insurance companies fail to tell patients what procedures they are paying for by CPT and ICD code. It doesn't help that medical insurance companies fail to provide information and/or education to the patient on alternative treatments that may be just as effective and less costly so that the patient can be an effective medical consumer before the service is provided. It doesn't help that medical insurance companies are more inclined to deny payment because of a clause in a "contract" that they don't make available to the patient. The medical insurance community simply doesn't want that kind of transparency. And the assumption they make is that the patient doesn't care when in reality, they do care but are prevented from doing anything about it. Patients know that excessive care results in raised medical premiums without an concurrent improvement in the quality of medical care; it doesn't matter whether they or their employer pays for it.
— RAP, New Jersey

13. - I am a 60-year old female with basic good health. Though I have had jobs with employer-paid insurance, I have never filed a claim. I tend to stay away from doctors. So when I received an offer with the a major international organization contingent on a cardiac consultation to decide whehter my asymptomatic irregular heartbeat was a problem, I was a cautious consumer because I was paying. I went through the physical exam, the EBTC Coronary Artery Scan and the Holter monitor. to the tune of $1500. The pictures weren't clear for the conventional stress test (no charge) so I was assigned the nuclear stress test at $2000. I didn't want a shot of radioactive dye, espcially when I felt OK, and the additional $2000 was beyond my health care nest egg limit. We reached an impasse. Maybe people think you just have to be hiding something if you don't go to doctors. I didn't get the medical clearance. So now I'm looking for a new job. And I don't care whether it has medical insurance.
— Carole kraemer, Washington DC

14.- Dr Jauhar is so right. And he hasn't even touched on the topic of the perverse incentives offered to surgeons in this country, where a surgeon has to bill a certain amount to be able to collect his/her salary.....creating fuzzy indications for surgical procedures.
Linking monetary incentives to healthcare has created a "business" out of what used to be a calling.
— Dr SVK, Boston

15.- A wonderful article, but what about the "pill pushing"? So many of my friends are on a variety of pills, each one producing side effects so another pill is added to counteract that one, and so on and on it goes. The pharmaceutical ads for every condition perpetuate the myth for the hypocondriacs that a pill will cure everything. (just don't read the side-effects).
— Linda, Stone Harbor

16.- Healthcare has a systemic problem. Although plenty of unneeded testing occurs, it is a product of a system in which all the players are out of whack, insurers, patients, doctors, and hospitals. We need to attack some economic factors. Most of us who are insured or on Medicare think we are spending other people's money. Until we have a stake in the game too, many tests are likely. See www.healthcaresoundoff.com for some intelligent discussion on this subject and the healthcare system in general. Good article.
— Steve Schuster, Ashburn, VA

17.- The good doctor points to one element of our health care crisis. The current political solution is to push universal insurance rather than care. That will make the insurance cartels and their allies the drug an medical device companies even richer. It won't improve the system.

Let's face a fact. We don't have the "greatest health care in the world" when the residents of countries like Jordan live longer.

The greed of the insurance trusts (they are exempt from anti-trust laws) is bloating out cost of business and government. That leads to a good portion of the off-shore outsourcing.

We need major reform of the entire system, legal controls with real penalties for abuse, and somebody like Teddy Roosevelt to make it happen.
— Jim, Oak Ridge, TN

18.- While I agree that the case as described represents an excess of testing and consultation, the author does not comment on whether any of the tests led to an appropriate diagnosis. If the last test, or the 6th consultant discovered and corrected a life threatening problem, for example if the cardiac catheterization revealed significant left main coronary artery disease would it have been worth it.

Most doctors practice appropriate medicine. Articles like this breed mistrust between patients and doctors. Physicians are forced by our system to assume the financial risk for providing adequate care.If you believe doctors earn too much money, you must shift the risk to another party, or no one will be able to practice medicine.
— Jeffrey Jackman, MD, Arlington

19.- I am wheel chair bound due to a spinal cord disease. Last year I went to the ER for abdominal pain. Over the next four days I saw 8 specialists. Because I was on bed rest not one of them knew that I did not walk, and evidently had not read my medical history. I was told I had pancreatic cancer and had 2 to 12 months to live. I refused anymore tests although my many doctors strongly objected. When I did not die in the next 6 months there was much confusion. It seems I had an enlarged lymph node that was not even in my pancreas and meant nothing! Many "tests" are read by human beings which can be very subjective. I am so glad I braved my doctors anger and refused what I did. None of the tests they wanted me to have would have made any difference except to cause me pain and expense. By the way- No one ever even faintly apoligized for what I had gone through.
— Joan, Warren,NJ

20. - People come into my office expecting tests: "Doctor, you know the x-ray won't show anything. I want an MRI. Why should I try medicine or therapy without knowing what it is first?" But Mr. Smith, if the MRI shows you need surgery would you have it? "Certainly not Doctor, but I want to know what it is. And besides I am entitled to the test. I have insurance."

Mr. Smith will go to another doctor if I do not order the test--which by the way will cost me in staff time to get the HMO authorization with no reimbursement to me. And if this is the 1 in 1 million case where something dangerous is found on the MRI I will be sued for not finding it.

So he gets the test.
— Richard, MD, NYC

21. - When I started as a cardiologist 32 years ago we didn't have all the fancy testing. You had to make a clinical decision based on your ability to examine a patient, take a history, a few x-rays, an occasional stress test and an ECG. On the whole we did reasonably well under the circumstances.

Then the attorneys discovered the pot of gold. Whereas the General Internist used to "quarterback" and integrate the care, getting consultative support when needed, a panic ensued. The internist deferred much of the patient's care to the sub-specialist out of fear of being sued. Ultimately the growth of medical knowledge expanded exponentially and more of the care did have to entail sub-specialist involvement and, in my experience, most sub-specialists make an effort to keep each other informed about mutual patients.

However, as the testing got more sophisticated, less and less attention was paid to the patient because there are limits to the accuracy of simpler methods. In addition, our lawyer friends encouraged the view that a physician was expected to be perfect. To be perfect you can not miss the one in hundred thousand chance that a 25 year old has an anomalous coronary artery that could cause sudden death, so you stress test all of them. What about the patient with asymptomatic coronary disease in whom the chief complaint has nothing to do with his coronary disease? So pains that aren't remotely similar to heart pains get the patient stress tested.

Even if you practice in absolute accordance with the published guidelines based on expert consensus you do not meet the lawyers standard. An acquaintance of mine did precisely that, and lost a suit because the patient he saw in consultation in the emergency room and on whom he obtained a negative stress test on, did not take his advice and follow-up with his primary care provider, stop smoking and get his cholesterol under control. That patient presented two years later with a massive, fatal heart attack, despite a heroic effort to save him. My associate, reading from the guidelines in court, was held totally responsible because, according to the plaintiff's attorney, he "didn't really care about the patient, just wanted to be done with him." Two million dollars later he is listed on the national registry as having been successfully sued for malpractice.

The result has evolved to the point where I am constantly having patients say to me that they have never been examined like I examine them before. Or where no one before me has actually touched the patient, after they have been submitted to the unnecessary risk of a dye injection and the high radiation dose of a CT scan to exclude an aortic dissection, and discovered that they had a muscle spasm that I could successfully relieve by massaging the trigger point. Or find a tender costochondral joint (rib to breastbone joint) that on palpation reproduced the symptoms. Even the radiologists are expressing concern about the level of radiation to which patients are exposed.
— Dr. Prior Generation, PA

22. - Dr. Jauhar provides an excellent and concise overview of the dysfunction of the healthcare system in the USA - all the better because he sees from a practicing physician's perspective all the non-value-adding activities (a.k.a. waste of resources) that incur costs, but often to the detriment of the patient. Dr. Jauhar illustrates the conflicting role of the physician as patient advocate - actions taken regardless of cost to others but often to the financial benefit of the provider him or herself - but also as the best suited link in the chain of healthcare delivery to weigh cost versus benefit of additional testing or other "treatment".

The comment by Dr. Krauss includes the normal list of complaints of providers that cite without facts. The complaints are completely unsupported by the facts. For example the cost of medical education which is in many ways subsidized by the federal government - i.e. financed by taxpayers - is irrelevant. It is an investment in human capital like any other. Gross payments to physicians - as well as net compensation to all physician specialties - via the RBRVS (resource based relative value scale) system have risen continually on average over the years. There is occasional revision downward of reimbursement rates for particular procedures where the existing rates are absurdly high (radiological procedures for example). Also the SGR (sustainable growth rate) mechanism instituted by Congress in 1999 to restrain overall growth in healthcare spending to growth in GDP - adjusted for demographic changes - has been overridden every year since then (aside from 2002) to permit increases in overall payments to providers in excess of the budgeted growth rate. Cumulatively increases in physician payments in total exceed the allowable amount budgeted for the 10 years by 25%. In other words in order for the mechanism to work as it should, physician payments as a whole have to be reduced by 25% to align them with the budget. Note that the median net compensation (equivalent to salary) of primary care physicians was nearly $190,000 and over $300,000 for all specialties in 2006. Gross payments are roughly 3 times those numbers.
— Wendell Murray, Kennett Square PA

23.- Dr. Jauhar touched upon a very important reason behind the extraordinarily fractured and high cost of medicine these days..simply that American society as a whole demands this way of practicing medicine.

The day that an average American simply accepts their own mortality and limits of modern medicine is the day that healthcare costs will come down.

As a physician, I do order tests "just to be careful and make sure" knowing that 90% of the tests I order have such low positive predictive value because of the demand of the patient that I do a "thorough" job.

People need to accept that there is disease in nature and that people do get sick and die..in spite of our best and many times superfluous efforts.
— Ashrock, Florida

24.- So-called pay for performance, or "P4P," is also part of the problem. Not only will doctors be inclined to overtest, but they will only overtest for the conditions being measured by the quality indicators! We've already seen some evidence of this. Furthermore, the flip side is that patients with complex medical conditions will be avoided.
— Rebecca D., M.D., Rochester, NY