Redundant tests waste health care dollars


Sounds simple, huh?

1 letter, 2 numbers. One of the B vitamins. It’s important in a number of body functions, particularly the nervous system and blood cell production. It’s in pretty much all meats and vegetables, and multivitamins you can buy.

To me, it’s also a good example of what’s wrong in health care.

Let’s take Mrs. Olde.

She goes to her internist, and is complaining of feeling weak and tired. So he checks a B12 level, thyroid labs, and other stuff.

A week later, she’s out with some friends, and trips in a movie theater. She breaks her leg, and lands in ER. She gets admitted to the hospital.

There she mentions that she feels weak and tired to the admitting hospitalist. So, with the usual pre-surgical labs, she checks a B12 level, thyroid labs, and other stuff.

She does fine in surgery, but afterwards has a mild anemia, which doesn’t improve. So after she gets out of the hospital she goes to a hematologist. This doctor doesn’t have any of the previous tests, and so orders another B12 as part of the work-up.

While she’s recovering, she’s taking Percocet for her broken leg. She mentions to her daughter that her memory is foggy, and so the daughter takes her to see a neurologist.

The patient comes to the neurologist. He thinks the problem is due to Percocet, but to cover himself he orders a head CT. Since he doesn’t have access to her hospital records, and she doesn’t have any of her previous labs with her, he orders a bunch of blood work, including a B12, thyroid labs, and other stuff.

Story over.

Now, a B12 level, according to Local Lab, costs $198. So this lady has had 4 done, for a total of $792, in less than a month. B12 levels generally don’t change that dramatically in a month, so only 1 was really needed (yes, I know some of you are thinking a methylmalonic acid level is more useful than a B12, and I agree with you. But that’s not the point here. And try getting Medicare to pay for an outpatient methylmalonic acid).

$198 isn’t that much, is it? But multiply it by thousands of patients a month with similar stories. That’s a huge amount of money wasted. And then extrapolate it to many other redundant tests: CBCs, TSH, chest X-rays. And then add pricier items (though not as commonly reduplicated) like CTs and MRIs.

I generally don’t order labs if I know a patient has recently had them. I try to get the old records, then order anything I need that hasn’t already been done. But many docs don’t do that. And sometimes the patients are less than helpful. They forgot they had stuff done 2 weeks ago. Or don’t remember the name of the doctor/hospital who did them, making it impossible for me to track them down (you’d be amazed how many times people have no idea what hospital they were in recently, or what doctor ordered their tests).

I’m guilty of this myself. Yesterday I admitted a guy to the hospital, who told me his outpatient work-up hadn’t included any labs. So I ordered a bunch. This morning I came into my office to find everything I had done last night was also done 3 days ago, and was sitting on my fax machine. According to the hospital labs, the total cost on these duplicated labs was $1278.

I don’t think the patent did this intentionally. He’d either forgotten, or (and this is common, believe it or not) thought that the labs his internist ordered wouldn’t be ones a neurologist would want, and therefore didn’t count.

Redundant tests, I think, are a huge waste of money. I’m not sure what the answer is here.

Some would say we need to have all these records in a huge database, searchable from anywhere, and protected by elaborate security checks. This would likely be the best answer, but I think all of us have huge concerns about the security and privacy issues involved.

Better communication between doctors would help. You have no idea how much I appreciate it when a referring doctor sends labs and test results in advance, or even with the patient. That way we all save time, money, and blood on further tests.

Another option is to put the patient in charge of their records. Some are good at this, bringing copies of labs going back to their childhood. But most don’t. Giving them a memory stick or CD with past tests sounds good, but those things can be forgotten. Or lost. Or not work on a different type of computer.

I don’t have an answer for this. I wish I did. A good solution on a large scale would likely save a huge amount of time, money, and aggravation for all of us.

Doctor Grumpy is a neurologist who blogs at Doctor Grumpy in the House.

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  • Justin

    I like your point about making patients more responsible for their records. It is simple enough, in outpatient land, for a patient to be sent with a packet of paper notes documenting labs and imaging tests. When they show up for a consult without this, it delays optimal care because I am working from a place of less information and I will only get all the info if I can get the referring office to fax it to me (a surprisingly difficult thing to get done sometimes). Maybe a simple paper record like we have patient’s keep for their immunizations. This would be larger, expandable file size, of course, but for one person it would not be too unwieldy.

  • Kaye Miller, RN

    I am all about engaging patient responsibility. There is a public misconception that if the physician has, for instance, the patient’s list of medications then the entire health care community has instant access. In this day and age there is no excuse for lack of information. We make it easy to learn; that is, when the patient wants to learn. Generally, people expect to be hand held through their entire process.

  • Margalit Gur-Arie

    The solution has been proposed over 40 years ago. In 1967 the American Academy of Pediatrics published the Standards of Child Health Care suggesting the following:
    “For children with chronic diseases or disabling conditions, the lack of a complete record and a ‘medical home’ is a major deterrent to adequate health supervision. Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place”

    Not just children, but every person should have a medical home, whether paper or electronic. Some are suggesting that patients should be responsible for managing such repository, but I seriously doubt that most people are capable and/or willing to do so. A primary care practice is, in my opinion, the logical place for such activities and in addition to maintaining an up to date record, a PCP would also analyze, coordinate and act on that information. Paying PCPs for these activities should be much cheaper that all those B12 tests……

    • Steven Reznick MD

      You make too much common sense to be listened to by anyone in position to bring about change.

      • Margalit Gur-Arie

        Probably the biggest compliment I ever got…. :-)
        Thank you!

  • Primary Care Internist

    how about medicare picking a universal electronic record system (eg. VA’s vista system), giving it for free to all entities that bill medicare, and conversely mandating the use of it for anyone billing medicare?

    voila, instantly available web-accessible elctronic records with labwork, imaging reports, operative notes, demographic/ contact info, specialty consultation recommendations, etc.

    this just seems so simple, doesn’t it???

  • Paul Watson

    We are living in the dark ages – other countries keep patient records much better than we do, although there can be gaps when people move between public and private providers.

  • Wellescent Wellness Blog

    While there is some fear with putting all the medical records in one central location, there are also problems with having patients in charge of their medical records, given how readily many people will misplace many of their possessions. A middle ground comes with the distribution of medical records amongst a number of electronic health record companies and the the use of a common interchange format to move records from one provider to another as needed.

    While a number of countries are doing better than the US, only a handful have really put in place health records that are universally available amongst health care providers. Until these sorts of efforts are undertaken and promoted by governments, considerable waste through redundant testing will continue.

  • Finn

    I work pretty hard to maintain my own records as well as requesting that my specialists send a report to my PCP each time I see them. And yet, somehow the reports from my specialists at Hospital B never manage to make it to my PCP or into my record at Hospital A. The only way to make sure it happens is the ridiculous Medieval method: request a written report from Hospital B, pick it up in person and hand-deliver it to my PCP at Hospital A.