The following is a reader take by Dr. SSS.
We talk about the current healthcare crisis, the wasted dollars in medicine, the rising cost of healthcare and yet there is no real increase in the quality of the care provided. Defensive medicine is a key to this waste of money in the healthcare system. Cutting reimbursement of physicians, recruiting mid-level personnel or switching to generic medications is like treating cancer with Tylenol. Even though defensive medicine is discussed, I do not think anyone outside medicine understands it at all.
I’d like to show the disastrous effects of defensive medicine with numbers. Let’s look at a hypothetical, yet conservative, estimate of the wasted dollars in medicine on musculoskeletal chest pain.
I am an internist and I frequently receive a calls from the ER asking me to admit a patient with chest pain, which on clinical history is “almost certainly” musculoskeletal in origin. However, my friends in the ER have already documented it as “rule out MI”. Now my “almost certainly” will hold no water in the court of law after a bad outcome. Thus, I’m forced to put the patient in for an overnight stay. Sometimes it is difficult for me to understand if I am really treating myself or the patient.
Let’s get back to the numbers. The two words “almost certainly” may be the most expensive words in terms of health care dollars. Here’s why:
* Consider that there are more than 100,000 primary care physicians in the United States (a conservative estimate)
* Assume a single “chest pain, rule out MI” admission costs $2,000 dollars (again, a conservative estimate, as one of my patients was billed $10,000 for a single night stay)
* Assume every primary care physician admits at least one “almost certainly” musculoskeletal chest pain for an overnight observation in the hospital at least once a week
Once we have digested these numbers, it is time to do the math.
If the above statements are true, the total amount of money wasted on an “almost certainly” musculoskeletal chest pain annually is:
100,000 x 2,000 x 52 = $ 10,400,000,000 per year
A whopping $10 billion dollars are wasted on a single diagnosis every single year. Even if you set aside $1 billion to pay the malpractice lawyers on a yearly basis, you still save $9 billion a year on a single diagnosis.
Putting needles and IV dyes into a patient who “almost certainly” does not need it is not standard of care. Every single day, the threat of malpractice suits forces well-meaning physicians to do so. Every single day, more patients go through unnecessary tests to protect the physicians from malpractice.
That, I’m certain of.
Dr. SSS is an internal medicine physician who blogs at CareerMedicine.com.
Related posts:
- Defensive medicine op-ed reaction
- Physicians don’t trust the malpractice system and why doctors order too many tests
- “Uniquely American tort laws” contributing to health costs
- Defensive medicine wastes money and hurts patients
- Cash-only medicine doesn’t necessarily mean expensive care
- Defensive medicine = $210 billion
- Defensive medicine is aggressive
{ 21 comments }
Consider the cost of treating viral respiratory tract infections with antibiotics. Where I work, anyone with a runny nose of 12 hours duration can get a Z-Pack, and lo and behold, their symptoms improve in 5 days. Charge for a level 4 visit, throw in a rapid strep assay or maybe even a CBC and monospot and the deal gets even sweeter.
And yet if the savy consumer is denied their drug of choice, they will likely tickle the system until someone fires off a script to make them go away. A clever ED physician may tell them, “you almost have bronchitis” to add some drama into the situation.
Don’t forget the cost to future generations of dealing with the megatons of these chemicals that we so irresposibly dump untreated into the ecosystem……
SSS is correct.
In outpatient medicine, nobody seems to discuss the high cost of defensive radiology. I seldom receive an x-ray report that reads “normal”. The report usually reads “cannot exclude X”, or “possibilities include …”, followed by a request for CT or MRI.
This defensiveness occurs even when there are no financial incentives, such as with HMO patients.
The cost of all this defensive radiology is staggering.
My guess is that dollar for dollar tort reform would the most efficienct means to lower healthcare costs. When surgeons come to Canada the difference in their style of practice is stark because of defensive medicine. The words “call me if anything changes or gets worse” do not come out of their mouths when they first arrive. The truth, as I see it, is that patients understand the uncertainties in diagnosis and have little desire to undergo unnecessary tests given the odds and reasonable options.
http://www.waittimes.blogspot.com
“The truth, as I see it, is that patients understand the uncertainties in diagnosis and have little desire to undergo unnecessary tests given the odds and reasonable options.”
Which requires that you take the time during consults to explain all of this to your patients. Can you do that in a 5 minute appt? You’re a genius if so.
After undergoing two years of repeated surgical biopsies myself, none of which I requested, I have become very much an advocate of less testing. Still, every time I log on to this site, I see posts from doctors claiming that “patients want tests.”
Try talking to your patients before jumping to that conclusion. I’m sure some would still insist on the tests. But if you order them automatically to CYA, you’re not doing diddly to confront the problem…and thus lose the right to complain.
Ten Billion for chest pains…of course not. The numbers may be right, but there is the fact of reimbursement. And that magic word only applies to people who have insurance, which is less and less these days. And assuming that insurance does pay…there is no way they will pay the entire bill. Can you imagine receiving 97 dollars for working a Full Arrest? However, I am upset that the doctors are getting shafted again. Great Post!
Alex ~D~
http://theapocalypsepapers.blogspot.com
anon 9:46, But that isn’t what happens at all. We are told we “need” to be admitted because of our age and nature of our pains and “I’m not comfortable sending you home.” As laypeople we are not qualified to second guess what a medical PROFESSIONAL has told us we “need.” Then come the next day when we are still alive, we get discharged with orders to see the cardiologist who we have never before seen or heard of. The hospital has already made our appointment for day after tomorrow. When we see him we then will have a stress test and echo. We willingly do it all because by now you have scared us to death thinking we most likely have something seriously wrong with our heart. And just who knows,, maybe we do have. So what is the answer? Do we go back to where most chest pains were given an H2 blocker or a PPI and sent home? I guess that would be alright unless you happen to be one the unlucky ones who was treated at the local ER for acid reflux, then went home and died of an MI. It certainly happened and it happened alot.
Alex,
I have used a very conservative estimate of $2000 an admission which includes hospital admission too, not just Doctor’s Bill which probably is only $100.
Alex,
I have used a very conservative estimate of $2000 an admission which includes hospital admission too, not just Doctor’s Bill which probably is only $100.
Anon 5:57 A.M. -
While there is no doubt that defensive radiology can be a serious a problem, particulalrly in the hands of inferior practioners, the larger blame for defensive medicine must be shouldered by the referring physician. Radiologists hedge because of the inherent lack of specificity in imaging, particularly plain film radiology, coupled with the unfortunate vacuum that we are forced to read in. Referring physicians have the distinct advantage of seeing all objective and subjective data with regard to a patient. In the case of pneumonia, which is a clinical, not radiographic diagnosis, a radiologist has only one piece of information to rely on – the image in front of him. Histories provided by referring physicians are mostly useless (cough if we’re lucky…usually r/o pneumonia). The lack of specificity in many imaging modalities further poses a problem when the initial probability of disease is vanishingly low (as is the case with most cya testing) – most positive findings are false positive findings and clinicians find themselves chasing incidental finding after incidental finding. Imaging begets imaging, even for the best radiologist, and the best way to end this madness is to cut it off at the source.
you are almost certainly correct
The best radiologists as well as the worst should be salaried employees of the hospitals which give them free overhead. That way, they have no monetary incentive to fudge. Still the best scam in medicine.
Additionally, as I lamented in a recent post, physicians (particularly primary care physicians) are often loathe to leave well enough alone, even in the face of a radiology report devoid of any recommendation whatsoever. I can’t tell you how how many times I see benign adrenal adenomas followed despite no recommendation on the previous report. I always give reasonable, evidence-based guidelines regarding lung nodule follow-up in my chest CT reports yet constantly see unnecessary scans being ordered.
Furthermore, the phrase “possibilities include…” is entirely appropriate in any report. It’s called a differential diagnosis. Look it up. You want more definitive answers, cut the patient open and look yourself.
“Histories provided by referring physicians are mostly useless”
Actually, I could write a history worthy of the NEJM without any impact on the radiologists near me.
But you can be darn sure I’ll hear about it if I neglect the diagnosis code on the request.
Agree with the blogger who calls it the best scam in medicine.
At most hospitals, one radiology group enjoys a monopoly — and acts like it.
Anon 5:39 PM -
It would be an interesting study to see if follow-up recommendations were more prevalent in private practices that earned income per case than in salaried hospital radiologists, similar to how ordering patterns increase for clinicians who have imaging equipment in their office. I honestly don’t know the answer. While I acknowledge that there are unscrupulous radiologists, the vast majority (if not all) of the the radiologists I have worked with including out-patient private practice folks, academics, and hospital-based non-academics share the same disdain for unnecessary imaging (though, obviously to varying degrees). I imagine this would not be the case if radiologists were scrapping for work. The fact of the matter is, radiologists do not need self-referral to keep the money flowing in – referring physicians are happily providing enough work to keep us busy for a long time.
If all insurance companies INCLUDING MEDICARE could implement evidence-based suggestions as the radiologist above does and based payment on those guidelines, there would not be a flow of imaging into the radiologist’s hands. However, when you have (as the Happy Hospitalist likes to say) the Medicare National Bank RVU scam coupled with the typical “fudge factor” seen in most xray reports, the ordering MD has no choice and, for the most part, no consequences of ordering the test. Not ordering tests can certainly bring legal consequences. The RVU system will most certainly destroy American healthcare (if it is not already destroyed) if it is not radically overhauled!!
“At most hospitals, one radiology group enjoys a monopoly…and acts like it.”
Huh? Last I checked patients and physicians had a choice where to go for imaging. My hospital-based radiology group competes intensely with surrounding groups for business. If you’re referring to inpatient imaging, then yes, the hospital group has a captive audience, but it’s in outpatient imaging that the money is made.
I’d also like to hear more about how RVUs drive doctors to order more imaging tests. I’m not sure I understand this.
And please stop using the term “fudge factor” – it implies an intent to defraud which is a gross mischaracterization of radiologists who hedge (all of us at one time or another). As the original commenter on this issue stated, this is a manifestation of defensive medicine the purpose of which is to protect from liability – not unlike every other doctor in this country.
This defensiveness occurs even when there are no financial incentives, such as with HMO patients.
Really? Do doctors who order unnecessary tests ever ask “do you have HMO or do you have high co-payment or percentage-based co-insurance”? Doctors don’t even know what type of insurance a particular patient has. Do you order fewer tests for people who pay from their high deductible or who pay 30 of cost after deductible? You keep blaming the fact that we aren’t aware of the costs on your overtesting, even though many of us do pay and you couldn’t care less. The reason that we don’t question your ordering tests isn’t as much the fact that we don’t pay, but the way you present this tests to us – as something we may die without.
We aren’t exactly told “you don’t really need this test, but I want to subject you to its risks, make you pay for it, in order it to protect my own a**”. No we are told “we’d like to order test X to rule out Y” or “we’d like to keep you overnight”. So we think that we are in real danger of Y and since to most of us our lives is more important, we agree to it, even if we have to pay later. Because the way you make it sound, we may die otherwise. If you were to just add the probability of the thing you are trying to rule out “I’d like to order test X tor rule out 1/100000 chance you have Y”, then you could say that you know we actually want the test. Sometimes you even lie – e.g. if someone asks you “would you order the same test on your relative”, you say “yes” even if the real answer is “no”.
You don’t really seem to understand how vulnerable we are when we are in your office or, especially in the ER. The environment can be pretty intimidating to us. Most of us don’t even think that we have an option of questioning “doctor’s orders”. We trust you.
Incidentally, it wouldn’t take even 5 minutes to convey to us that the probability of what you are trying to test for is extremely low. It’ll probably take under 1 minutes. You just don’t want to give us choice because heaven forbid we might refuse. You don’t want us to refuse.
So stop blaming HMOs that many large employers stopped offering anyway. I work for a Fortune 500 company that employs hundreds of thousands of people, and it stopped offering HMOs years ago because they are expensive. Now it is often PPO where we pay deductibles and percentages, so yes cost are important to us. You just think it is perfectly fine to use us as your insurance – take our money to protect you – even those the majority of peole don’t sue.
When the physician who will take an oath and admit he has ordered unnecessary tests and billed for them appears, then we can have an honest discussion about the alleged costs. Until then it’s just made up numbers for the purpose of tort reform lobbying. Despite the fact that even in states with draconian tort “reform”, doesn’t lower the costs to the patient or the system.
Canada would be a useful comparison, IF the US had the social safety net of Canada. When physicians want to fully embrace Canadian style healthcare, then what they do with regard to the alleged defensive medicine will be relevant.
“If the above statements are true, the total amount of money wasted on an “almost certainly” musculoskeletal chest pain annually is:
100,000 x 2,000 x 52 = $ 10,400,000,000 per year”
OK, but you are missing something pretty important. You probably pulled your numbers out of your butt, but I’ll use them anyway.
The word “almost” is there. Please quantify it. Is “almost” equal to 90%? If so, then the cost is about $20,000 per life saved, right? Seems worth it. OK, maybe “almost” means 99%. Now it is about $200k per life saved. It still seems worth it. You have to get to 99.9% certainty before you reach $2M per life saved. I think it is around the $M mark that people might start debating whether or not it is worth it.
So, based on clinical history, how certain can you be that chest pain is not MI? 99.9% certain?
I seldom receive an x-ray report that reads “normal”
I call bullshit. I am a radiologist, and I can conservatively say that half my reports have a summary section that reads “Normal”, “Normal for age”, “No acute disease”, “No significant change”, or “No significant abnormality.” This is especially true in the ER.
I may mention the benign adrenal adenoma or hepatic cyst or fibrous cortical defect in the body of the report, mostly to spare myself from getting calls from clinicians who see something on the images and don’t know what it is, but I make a real effort to be definitive in my interpretations. If there’s a lung nodule that has been stable for three or four years, my interpretation will read “Stable lung nodule. No further imaging follow-up is needed.”
When I hedge in a radiology report, it’s because there truly is no way to determine what some vague abnormality really is without further testing. A smudge on a chest X-ray can be a focal pneumonia, atelectasis, or an ill-defined neoplastic mass, among dozens of other possibilities.
You guys on the front lines remember the times I hedge about inconclusive imaging findings, because you have the patient there in front of you with a fairly obvious clinical diagnosis that I am not necessarily privy to. You don’t take notice of the dozens of time per night that I am able to easily dismiss benign findings or artifacts that would otherwise have you scratching your heads for twenty minutes and perhaps over-treating or mis-treating your patients.
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