Why doctors order so many tests

And it’s not always because, as is portrayed in the media, that they get rich from doing so.

I, or many other doctors, do not make a dime if I send a patient for an MRI.

Rather, it’s because there is financial incentive to see and churn through as many patients as humanly, or in some cases inhumanely, possible. Chris Rangel has a nice list, giving 10 reasons why doctors order so many tests. Part of it is placating the patient, another part is defensive medicine (“the common perception among docs is that it’s far easier to defend oneself in court using the solid facts of test results than to explain why a test was NOT ordered”), but those reasons, combined with the pressure to see lots of patients leads to this:

The physician intentionally places themselves in a situation where they are seeing a ton of patients a day and the best way to manage this is to order mega testing rather then to take the time to do a proper history and physical to determine if any testing is needed at all. Mega testing keeps the patients satisfied that something is being done. It keeps the lawyers away and it allows the physician to see far more patients per day then they realistically or safely or ethically should.

True, there are instances where doctors who own MRIs self-refer, and thus gives himself a financial stake in the tests he orders. But that’s a relative minority of cases.

Far more important are the financial incentives pressuring doctors to maximize quantity, which naturally leads to ordering lots of tests.

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  • NoVA doc

    Sadly, our practice sees a good number of patients who expect an MRI for any severe ache or pain, indicated or not. I do my best to tell them that musculoskeletal MRI is best used as a roadmap for surgical or fluoroscopic intervention, but too many people seem to believe that it will them feel better. Am I a physician, or a salesperson?

    There are two diagnostic MRI machines here from competing practices just 1/10 of a mile from each other. There’s almost no waiting, but hardly an ideal use of resources.

  • Rezmed09

    Here is an extremely important point which is poorly written:
    “It placates the patient. This is kind of like number one in which the doctor doesn’t know exactly what the problem is but feels that it’s safe to threat the symptoms and see what happens. However, the patient is operating under the erroneous assumption that expensive testing WILL revival a cause for their symptoms and this will lead to effective treatment. Keep the patient satisfied and happy.”

    Next to Cover-My-Ass testing, in my salaried practice, “placating testing” is the most common reason for unnecessary over utilization. The way to fix it is to have patients pay more for testing which falls outside of strict guidelines. But that will never happen. The only way this will be fixed is by burdening PCP’s with all sorts of paperwork for all the expensive tests. It will reach a point where docs will not order the tests because it will cost more time to actually get the test.

  • me

    gawande would have you believe that not only do doctors primarily order tests to get rich, but that this is the central problem in american healthcare.

  • SteveBMD

    It’s also far more efficient for me to order the test myself (even if I know it was done 1-2 weeks ago somewhere else) than to spend the time trying to track down the results of the last test.

  • dockj

    Chris missed one important point. The inefficiency and lack of connectivity of our health care system in general. The patient may have symptoms that legitimately warrant further investigation with said expensive test. The sad part is that test may have already been done by another provider in the building next door. But with poor communication between primary care providers and specialists plus the abysmal lack of ability to access records from hospital systems in a timely fashion, especially if said physician isn’t in the network for that particular hospital, that test might as well have been done in Siberia. Even sophisticated patients can get tripped up in our medico-lingo and not understand that the same test is being redone until it’s too late, or they are not empowered enough to question the need for it. Perhaps the promise of PHR’s and HITECH funding for HIEs might actually fix this reason, for there is probably enough waste to fund it.

  • pcb

    kevin,

    Actually, you do benefit financially from ordering tests. A detailed look at the coding requirements shows that studies ordered or interpreted makes a visit more “complex” which will often allow you to code higher. While this is not the same level of incentive as someone who co-owns an MRI or CT or lab, it still might benefit you financially.

    Additionally, prescribing meds also will often make a visit more complex, so just giving the antibiotic for “sinusitis” or “bronchitis” instead of just calling it a cold and counseling the patient, can make a doctor more money.

  • http://www.howtolivealongerlife.com Brian

    This strangely makes me think of real estate brokers and mortgage lenders back in 2004-2005. The financial incentive was in making one more loan and not on making quality loans only to those who could afford them. In this case it is patient volume that is rewarded rather than appropriate patient care.

  • Paynehertz

    Another reason doctors perform so many tests is they get kickbacks for them. This is also true of many prescriptions they write as well.

    http://www.aconsumerfraudlawyer.com/html/links/mri-scamming.html

    The profits some of these doctors are making through these scams could be the driving force between the recent surge in imaging procedures. Many believe medical imaging to be the fastest growing health-care service in the U.S.

    Doctors in the United States ordered over 400 million imaging procedures last year, compared with only 281 million in 2000. But critics say it is hard to know how much of that growth has been a result of illegitimate referrals and shady business dealings, and how many are a result of a genuine rise in the need for imaging.

    “I’m not sure anybody knows the scope of [the problem],” said Dr. David Levin, a radiologist at the Thomas Jefferson University Hospital. “It’s big.”

    Levin co-authored a study that found about $16 billion in unnecessary imaging was recommended by doctors who made money performing the tests themselves.

    It’s important to note that the $16 billion is an estimate of the number of unnecessary images done by doctors themselves, and not the amount received from kickbacks from outside labs, so the idea that this is rare is clearly not true. The total fraud of both self-referrals and kickbacks from outside labs will of course be higher.

  • JordanGMD

    Reason number one on the list is a bigger problem than most people realize. From a medical perspective, it seems obvious that lack of knowledge, training and confidence lead to more testing (a sad commentary on today’s physicians considering the scope of the problem). Among radiologists (I am one) it’s very clear that it’s the worst of us who recommend follow-up after follow-up even on the most benign-appearing stuff. Unfortunately, if you ask the public, the most respected docs are usually the most “thorough” (translation; explore every possibility with extensive diagnostic testing). In fact, this was the number one trait admired in doctors in a recent survey. The featured doctor in a recent big city magazine’s “Best Doctors” issue was a notorious crazy over-orderer at the hospital I trained at. Ironically, the article alluded to this fact and portrayed it positively. It’s this disconnect between public expectation and medical reality that is the biggest hurdle to health care reform.

  • Anonymous

    Is what pcb says true? If so this is the most perverse incentive I have ever heard. Why isn’t this discussed more as a source of waste in the system? This is fee for service taken to a ridiculous extreme – you’re billing for a service provided by someone else!

  • Corinne Tampas

    Re SteveBMD: “It’s also far more efficient for me to order the test myself (even if I know it was done 1-2 weeks ago somewhere else) than to spend the time trying to track down the results of the last test.”

    Good grief! Yes, it’s all about YOU.

    Running up costs, making patients run around in circles, and exposing patients to additional radiation, dyes or whatever, is more efficient.

    Docs better be careful. With this attitude, doctors will rank below lawyers, used car salesmen and politicians in no time!

  • alex

    It may be ONE factor in upcoding a visit but the idea of ordering tests just so you can POTENTIALLY (if other complicating factors are present too) make an extra 10 dollars on a return patient is hilarious. Plus nobody I know actually considers that when deciding the complexity level of a visit. So no, it’s not really a factor.

    And that $16 billion study was written by a guy with an axe to grind. Since the radiologists are having their business undercut by self-referring cardiologists and others where they don’t get paid to interpret it, they have been pumping out literature showing that it’s all “fraud” to support self-referral restriction legislation. Which some of it surely is, but they obviously have a dog in the fight.

  • http://sideeffectsmayinclude.wordpress.com whitny

    1) If doctors order extra tests for the purpose of placating “demanding” patients, how might doctors improve patient education and communication so that patients understand how appropriate these diagnostic measures may or may not be? And how can there be a financial incentive for churning through as many patients as possible if this strategy prevents you from fully assessing, diagnosing, and treating your pateint? It seems this type of sloppy medicine would make you more vulnerable to lawsuits, and the benefits of mega-testing would not compensate for the risks of half-assing your practice. I’d think that any good litigator could recognize a case mega-testing and build an argument for incompetence around it. Is the cover-your-ass approach of defensive medicine more or less effective in pleasing patients and preventing lawsuits than spending enough time with patients to gather needed information, providing empathy and education, communicating effectively, and offering your patients targeted diagnosis and treatment? I’m not making any assumptions about the answer to this question: for all I know, patient-churning, mega-testing and sloppy practice really is more financially rewarding (or less financially risky) than judicious, patient-centered and thorough practice. Yet it seems we’ve known for quite some time (remember the early ’90s?!) that the simple act of listening to patients may help prevent some lawsuits (Lester & Smith, 1993. Listening and talking to patients: a remedy for malpractice suits? Western Journal of Medicine, 158(3), 268-272).
    2) Doctors practicing defensive medicine in an inpatient setting would be wise to seriously advocate for appropriate nursing staff levels with reduced nurse to patient ratios, since patient mortality and litigation increase as nursing staff decrease (Garretson, 2004. Nurse to patient ratios in american health care. Nursing Standard, 19(14), 33-37). Perhaps a well-staffed nursing environment, combined with the sorely needed improvements in communication that dockj mentioned, would curtail some of the “need” for defensive or redundant medicine.
    3) How do the financial incentives of plastering ads all over your blog compare to the financial incentives of churning through patients?

  • ErnieG

    Alex- what pcb says is true. If physicians are not aware that ordering tests increases your complexity for billing purposes, then they are not familiar with how insurances and Medicare audit. $10 per patient visit may not sound like much, but it can be a good percentage of payment. The statement that nobody actually considers orders to generate a level is not true (I’m a physician and I do); whether most physicians do is not clear to me, but insurances certainly do.

  • Steve B

    Re: Corinne Tampas: “Good grief! Yes, it’s all about YOU.”

    No, it’s about two things, most definitely NOT about me:

    1) The patient: The patient receives more appropriate, efficient, and convenient care if he or she (and I) have the data & information up front, rather than waiting the days or weeks to get results of previous tests (if the prior provider even returns my phone calls).

    2) Cost: The point of my initial argument (apparently lost on you, so quick to vilify the physician) was that it actually costs MORE on personnel, phone calls, paperwork, HIPAA compliance, and overall red tape, to get the results of prior studies, than to repeat the study. It’s unfortunate, but that’s our “system.” See dockj‘s post for a similar view.

    Finally, I agree with your point about exposing the patient to the adverse effects of some tests (radiation, chemicals, other risks). I absolutely consider this factor and provide as much information as possible to the patient, and ultimately let the patient make the decision.

    So is it “all about me”? Yes, in the sense that I want to be the best doctor– ie, to provide the best care to the patient and the least costly care to the “system”– that I possibly can.

  • R Watkins

    As a primary care doc, it costs me at least $100 to order an MRI (completion of pre-authorization forms, scheduling test, tracking results, notifying patient of results, arranging follow-up). And I’m doing that to get $10 for an upcode (which requires MUCH more than just ordering one test: exam, history, ROS etc. also have to be appropriate)? Give me a break!

  • Melben

    I agree with Paynehertz, every doctor who sends a patient to get lab tests done does receive a commission for each one. On our lunch break a few months back a rep from a lab came to see Dr. Fernandez and mentioned %10 commission on all patients he sent to their clinic…

  • ErnieG

    R Watkins– You may be correct about the MRI, but ordering a few blood tests/x-rays at an exam costs you nothing, and if you know about how notes are audited, you’ll realize how most physicians are undercoding because they are not taking into account what you actually are doing and not documenting correctly or adequately. T (I am not advocating the current coding, in fact it is hard to understand and I am convinced that it is designed against the physician, does not benefit the patient, and really only used to deny payment)

  • Rezmed09

    Whtny,
    There aren’t enough primary care docs to spend 30 min discussing with patients why they don’t need that MRI for chronic headaches that they have had for years. Or the the second MRI and 4th CT for that matter.
    Folks want to blame docs for not giving them everything they want. How can 15 minutes in a doc’s office stack up against 25 intervening hours watching TV medical shows and drug ads and blogs about what doctors miss. In this environment a large portion of people will only be placated if they get unnecessary tests. If they don’t get it their will be wailing and complaints: lawsuits (especially for the one in 10,000 bad outcome or missed DX) , complaints about rationing, or uncaring physicians.

  • Corinne Tampas

    SteveB:

    “1) The patient: The patient receives more appropriate, efficient, and convenient care” …..

    Convenient for whom? Many medical tests require pre-authorization from private insurance companies. A simple blood draw requires the patient to travel to a lab and wait his or her turn of anywhere between 10 and 45 minutes; a procedure such as an MRI can have a wait of up to two hours (even with an appointment) plus the time it takes to conduct the MRI. Of course, once the new medical tests results are returned to you, the patient must reschedule another appointment with you so that (after waiting in in your reception room) you and the patient “have the data & information up front”.

    “rather than waiting the days or weeks to get results of previous tests (if the prior provider even returns my phone calls).” …..

    Then, there would be no difference between the private health insurance system and the purported inefficient government option (or single payer system) as it is the prior provider, another physician, that is creating the log jam?

    “2) Cost: The point of my initial argument (apparently lost on you, so quick to vilify the physician) was that it actually costs MORE on personnel, phone calls, paperwork, HIPAA compliance, and overall red tape, to get the results of prior studies, than to repeat the study. It’s unfortunate, but that’s our “system.” ” …..

    No, the argument that the present system is completely inept is not lost on me. Your statement is an excellent argument for the president’s suggestion that all medical records be computerized for easy access.

    As for vilification of the physician, I have not vilified physicians, just one who orders duplicative medical tests for patients that are coping with an illness, long waits, and medical bills.

  • http://www.takebackmedicine.org jasonc

    As an anesthesiologist, we order tests on top of tests to make up for the tests that never ended up in the chart but the surgeon swears were drawn. So it goes.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Beyond defensive medicine and personal enrichment, there is another explanation of why we physicians practice too much medicine. The profession has evolved into a culture of diagnostic and therapeutic excess. This is the new way that medicine is practices. We don’t rely upon our histories and exams. These are mere springboards for launching into a higher orbit of tests, more tests, consultations and lots of prescriptions. This cost all of us money and results in anxiety and medical complications in patients.

  • http://lewinreport.acc.org Dr. Jack Lewin, CEO, American College of Cardiology

    As physicians, our first and foremost concern is the treatment of our patients, and we should be allowed to take every step necessary to ensure their well being. But, to say there shouldn’t be a thorough assessment of the way imaging services are being utilized would be a tremendous disservice to those patients, and the entire health care system.

    Still, there are ways to improve both the quality and efficiency of diagnostic imaging, while lessening the financial strain they place on our health care system. At the American College of Cardiology, we are working to reduce the rate of inappropriate imaging by creating evidence-based guidelines that facilitate the proper and judicious use of imaging services. These appropriate use criteria are crucial to helping physicians determine when imaging should occur, while appreciating the patient’s clinical situation, scientific evidence and the local health care setting.

    To learn more about the ACC’s efforts to establish appropriate use criteria and reduce unnecessary imaging, visit the Lewin Report at http://lewinreport.acc.org.

  • SteveBMD

    Corinne Tampas:

    It’s good to see that we agree that (a) the system is inept, (b) patient inconvenience should be avoided at all costs but is sometimes necessary– at least in the current environment– to make informed medical decisions, and (c) access to all medical information (as in a computerized EHR system) is essential for efficient medical care.

    I can’t help but wonder, though, why your posts seem to accuse me of resisting the “government option”. I’m not defending the status quo one bit. The AMA does not speak for me, I’m not in it just to make money, and I fully support a nationalized system, as it would make my job more rewarding and my patients would clearly benefit.

    (BTW, Melben, re “every doctor who sends a patient to get lab tests done does receive a commission for each one“. This is patently not true. I’ve received ZERO for any tests I’ve ordered.)

  • Rezmed09

    Dr. Lewin,
    I am skeptical of your efforts to reduce unnecessary diagnostic imaging. Many cardiology practices are financially benefiting from over use of Echo’s, Stress Echos and Caths. In a city nearby >50% of Cath’s are normal.

    In light of the COURAGE trial and the pre-op eval studies, I am surprised that there has not been any significant decline in the number of Pre-op and non pre-op Caths and stents and tests. Some of this is related to Medical Mal concerns, but still, the cardiologists near me are going all out to do lucrative procedures with little clinical benefit. I do not live near McAllen Texas, but can certainly see similarities.

  • A Rheumatologist

    @ Melben: please contact me. Someone is ripping me off because I’ve never gotten a dime from ordering a test. I want my money. Perhaps you can help. /sarcasm

  • Larry

    So the consensus is that over-testing is multifactorial, including: direct MD incentives (e.g. owning stake in MRI facility), indirect/conflict of interest incentives (upcoding visits to bill more), MDs just wanting to placate patients, MDs taking too many patients to churn for fees to take proper time with each patient, kickbacks from testing labs, and defensive medicine in a medical-legal sense.

    Yet when MDs and the insurance lobby speak to the public, its just all the LAWSUITS that are responsible.

    The fact is that the excessive testing and overutilization that is grouped under “defensive” medicine is a problem that is PRIMARILY due to financial incentives within the medical profession, not to mention outright billing fraud (e.g. Medicaid fraud) that is a huge burden on the system.

    But without “defensive medicine” costs (which are mostly non-lawyer/lawsuit related) the medical lobby has to confront the actual numbers that all costs of the US Legal system/malpractice law are 2% or less of US health care spending, per the Congressional Budget Office and every reputable study.

    So I ask you, when you admit that the “defensive medicine problem” is mostly MD created, will you acknowledge, at least as an economic matter (psychological reactions/stress issues aside) that medical malpractice cases are a miniscule part of the overall economics of US health care spending?

    Or will you just continue to bash “the lawyers.”

    And yes, I am a lawyer, and proud of the work that I do. I take on cases where real people need real help to make up for problems caused by real malpractice. And I’m truly sick of how, when MDs speak to each other, they acknowledge that most of the major problems in an otherwise excellent system of care are self-created, or due to structural/financial issues, and yet when they speak to the public, the “message” is: if only people had no right to bring a civil case for malpractice, then every patient would get the medical care the President has, at half the cost, and you’ll be taller and better looking.

    Just my reaction.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Larry, I completely agree that there are many reasons why physicians order unnecessary tests. They should all be examined. Litigation fear is a particularly potent defensive test generator and should be scrutinized. Of course, tort reform can’t cure it all, but it would be progress.