It’s commonly thought that health care in the United States is heavily dependent on diagnostic testing.
But how do we compare with the rest of the world? Perhaps these graphs, courtesy of the New York Times can provide a stark illustration.
Here’s the data regarding CT scans, showing the number of tests per 1,000 people. Guess which country’s on top:
Same story with MRIs:
Of course, there are plenty of reasons for this, including the widespread practice of defensive medicine, and a fee for service payment system that rewards some doctors (i.e. those who own their own machines, which not all physicians do), among others. In other words, perverse systemic incentives within our health system.
But patients bear some responsibility, as well. There are some who believe that more tests is better medicine, and to that end, an expectation that the “best” health care includes as much testing as possible. It is up to the medical profession to change that mentality, and educate patients about the risks of these tests. CT scans and the growing concern with radiation, for instance.
There is no single magic bullet. All of these variables have to be addressed if there’s any hope to decreasing the number of tests that we perform in the United States.
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A more telling tale for the healthcare reform debate would be a chart showing the cost of CT scans in a ratio to an average office visit for
the various countries. If you want to move the focus point from what is most valuable make sure that intelligent input from a thoughtful clinician is reimbursed at a comparable rate to input from an automated scan. If your arguement that profit motive is the chief cause, then change the payment paradigm to more closely match a 2-4x cost for these scans rather than 10 to 20x cost versus an office visit.
You should also mention that outcomes for disease are BETTER in the US than in other countries specifically in cancer and heart disease. When you correct for the incredibly high accidental death rates from trauma (which is NOT a problem fixable by the health system) the US leads the world in life span (as opposed to 37th if you include the disproportionate trauma numbers).
Despite some people’s wishes, we do get outcome improvement from more testing. The question is “at what price?” But pretending doctors don’t get any useful information from these tests is naive.
If malpractice went away tommorrow there wouldn’t be any change in the level of testing.
As mentioned, some docs own these centers and get paid. Most hospital economically credential doctors, so those that don’t order tests get shown the door.
All doctors benefit financially because they can order and read the results in a matter or minutes and get the same office visit fee in a fraction of the time. (without much clinical skill) Often the diagnosis comes to them on a silver platter and from there the next steps are obvious.
Until time-consuming, physical diagnosis pays as well per hour as having a machine do it for you, then this will continue.
And again, defensive medicine has absolutely nothing to do with this, unless it is the defense of a doctor that can’t do an H and P and reach a diagnosis!
It has become a culture to order more of imaging and honestly which patient would take the risk and say’ Do I really need this doc?” Malpractice has SOME role, majority has to do with culture, if doctors owns ct scanner, does not spend enough time to get good history because reimbursement is poor to spend time with patient etc. Reasons are many and most don’t benefit patient or our fiscal status of this country because we are escalating costs like crazy with such behavior.
I recall reading somewhere (one of Atul Gawande’s articles?) that the likelihood a patient will receive a CT scan or MRI is directly related to the number of such machines available in the community where the patient is located. If we build it… patients will come…. and insurance will pay.
I do IME’s as a sideline to my regular practice. I do one a month, maybe every other month, so not running a IME mill.
I had one, a few months ago. Auto accident. I saw a dozen CT’s and MRI’s done over the course of a year, just for the injured areas from the accident. Different medical groups, person did some doctor-shopping to complicate matters. But many of the studies were done by different doctors in the same multi-specialty group. Same structure, say a C-spine or a shoulder or a L-spine, gets the same study four times within a year, when there is no change in the patient, but a different doctor. Sometimes across town, but sometimes down the hall in the same group.
On more than one occasion, I have written in the IME report that there should be a primary physician designated, with all work going through that practice or ordered by that practice. Sometimes these cases where there is no one designated in charge, the system just goes wild.
How can the NY Times’s article be accurate if the following is true?
From the Frontline (PBS) special ‘Sick Around the World’:
“[The Japanese] have nearly twice as many MRIs per capita as Americans, eight times as many as the Brits…”
They – the Japanese – have twice as many, get them for a fraction of the cost, are ‘in love’ with technology (according to Frontline) and use less per capita? How does that compute?
I work in an ER. I order lots of CT’s. I order them on people that dont need them, because there is always an outside, miniscule chance that you will miss something if a CT is not ordered. it is the best imaging for a lot of things, and really really good in most situations where a dx is unclear.
If malpractice went away tomorrow, I would definately order less testing, across the board. not only CT scans.
but the best advise I got as a resident was ‘it is better to spend the patient money than to have them spend yours’ this defines my practice model.
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