Ordering tests may take food out of the mouths of our patients

by Tarcia Edmunds-Jehu

Sitting in an exam room I am watching my patient struggling to ask a difficult question that she clearly does not want to ask.

After several attempts at starting and a few half finished sentences she finally manages to mumble a request for help with obtaining food for herself and her two daughters. She is a 41-year-old woman, 32 weeks pregnant with her third child, and working a full time job as a CNA in a local nursing home. Her husband is also working full time as a janitor. At her initial visit she denied any issues obtaining food for herself and her family, and declined any referral to social services.

“Has the work situation changed for you or your husband?” No. “Have you always had difficulty getting food and did not want to ask?” No. “Is there some reason you need more food than you needed before?” No.

“Is there some new expense that is taking money that you used to be spending on food?”

Tears begin to flow and she starts to talk. She tells me that she had been in this country for 5 years and never had public assistance of any kind. She talks about her long hours working 2 and sometimes 3 jobs in order to have enough money to keep her family afloat. She talks about putting herself through school to become a CNA while still working to pay her bills. Until last year she was doing this alone, making not only money to provide for her family, but also the money needed to bring her husband here. She had never asked for help or let her children go without. But now she is unable to pay her bills and buy food. What is the tipping point for her ability to provide for her family?

Three ultrasound bills from this pregnancy.

She is 41 and had opted for an early screening test at 12 weeks that combines ultrasound and blood tests to give an estimated risk for Down Syndrome. She made this decision after a visit with a genetic counselor and had the test despite the fact that the results would have no effect on the outcome of her pregnancy.

At 18 weeks she had a fetal survey ultrasound that patients have routinely to check the anatomy of the baby and rule out anomalies.

At 30 weeks she had an ultrasound to check the growth of her baby because she was over age 40. This is following hospital protocol; despite the fact that there was no clinical indication her baby was anything but well grown.

This patient had private insurance through her job. Very few of my patients have private insurance, and at that time I worried less about a patient with a full time job who had private insurance meeting her needs than I did about a patient on welfare with state insurance. It didn’t occur to me to ask a patient if her medical bills were paid in full, or if she was responsible for paying a percentage or had a deductible.

The patient had insurance that would pay 80% of procedures, including ultrasound. Her insurance had deemed her 18-week fetal survey as necessary and were paying 80%, the other 2 ultrasounds were not considered necessary. She had a bill for close to $1400 that she had been paying off weekly for three months.

It could just have easily ended up that I would never have known about these bills, and in fact that may have been the case in the past with other patients.

We almost never think about what a test costs or whether it is paid for. Trying to find out the cost of a test is sometimes almost impossible. We almost never stop to think if a test is really indicated, or if the results will change the course of their treatment.

As providers we order tests because they are there, or because it’s easy, or because everyone gets them, or because we are scared if we don’t we’ll be sued, or because of arbitrary protocols. Sometimes we order tests because it’s the best thing for a patient.

No one orders tests thinking we might be taking food out of the mouths of our patients and their families, but sometimes that is exactly what we are doing.

Tarcia Edmunds-Jehu is a nurse-midwife.

On Labor Day Costs of Care, a Boston-based nonprofit, offered $1000 prizes for the best anecdotes from doctors and patients that illustrate the importance of cost-awareness in medicine. Two months later we received 115 submissions from all over the country – New York to California, Texas to North Dakota, Alaska to Oklahoma. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, but also because they unveil how commonplace and pervasive these types of stories are. To learn more about the contest and read more of our stories please visit www.CostsOfCare.org (Twitter: @CostsOfCare).

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  • http://natickpediatrics.net Rob Lindeman

    Nice piece, Tarcia. Congratulations!

  • http://www.birth-smart.com Birth Smart

    Thank you so much for this sensitive and insightful post. As a childbirth educator, I strongly encourage women to explore all their options and advocate for themselves as they make choices for their unique situations. These seeds were planted in me many years ago by a wonderful OB who offered me an amniocentesis, presenting it in a way that truly made me feel it was my choice, (rather than simply telling me that it was the protocol for my situation). I know that care providers have tremendous pressure on them, but I hope that stories like yours can remind all of us how important individualized care is.

  • Smart Doc

    I suspect the very same woman will not be as kind to you, along her vicious trial lawyer, the unfriendly judge, and the irate jury, as you sit in court with the a malpractice case for missing the diagnosis.

    • Dave

      Somewhat. Having a baby is expensive. Is it known whether she had a maximum out of pocket with her plan? If, say this was set at 2k for an individual, she would probably hit it even with a “normal” pregnancy, in which case the extra testing doesn’t really matter (she’s paying 2k out of pocket this year no matter what).

      Also, even with budget cuts, as long as her family income is at the 133% poverty level she should be able to get medicaid to cover her copays (pregnancy is a special case). Was this option explored? I have insurance for my family, but when we went to apply for WIC (she did enroll in WIC right?) they enrolled her in badgercare (without us even asking about it).

  • imdoc

    “We almost never stop to think if a test is really indicated, or if the results will change the course of their treatment…”

    Speak for yourself. Testing and protocols exist for a reason

    • pj

      I agree… Who’s “WE,” kemosabe?

  • http://kodzisp@yahoo.com Patti

    Smart Doc-really? Did you read what you wrote? Do you practice only defensive medicine or what is in the best interest of the client? Do what is right and only what we know to be right-help each other. In the end we will defend each other and agree-that practitioner did what is right!

    • Smart Doc

      I am just saying that there are people in the world (lawyers and judges) who are not as kind as the author of the article.

      • http://boxcuttersinc.wordpress.com Michael Wong

        Sadly, statistics show that you’re right, Smart Doc:

        According to Angela Dodge and Steven Fitzer (When Good Doctors Get Sued) – http://wp.me/p1fYJ7-hj

        * 25% of practicing physicians are sued annually
        * 50-65% physicians are sued at least once during their career

    • pj

      Smartdoc is right. And like most physicians, he/she likely treats patients, not “clients.”

  • Nicholas Fogelson

    You should write an appeal letter for her. The first trimester screening is cconsidered medically necessary per ACOG guidelines and will be approved on appeal. the growth scan may get approved if you can document a better indication, such as size < dates or poor maternal weight gain.

    You have the power to fix this please do so.

    Nicholas Fogelson
    http://www.academicobgyn.com

    Contact me if you need help I have great experience in how to win a good appeal ( which this is )

    • gzuckier

      probably true. the possible cost of a birth defect baby is something the insurers very much want to avoid, and paying for the additional test(s) might well actually be covered. communicating with the company via bill coding is not always perfect.

  • soloFP

    Shopping around for test costs also can help people. I have two independent radiology and ultrasound centers in my area that are 40-60% cheaper than my local hospitals on average. An extreme example is that the ER wanted a stat CT on a nurse who did not have insurance yet. The nurse asked how much? Cost would have been $2,000. The local outpatient center did one the next day, the same day that I called, for $400 cash. The hospital called later and stated they would offer the nonstat CT for $1,000. It pays to compare prices for labs and studies. Publishing lab fees and study fees would greatly help reduce the cost of medicine, as patients and doctors could price compare necessary labs and studies.
    A related example is the power chair. A patient was charged $7200 for a power chair through Medicare and his private insurance. Together they paid $5,000. The patient was told that if he had to buy it outright for cash or check, the company would discount it to $3,200. Charging high fees to insurance companies and Medicare simply adds to the cost of medicine.

  • Anonymous

    Rewards/punishments change human behavior. A doctor who faces a malpractice suit following a well intentioned test or avoidance of a test, will change his/her behavior to be more defensive. Similarly, a patient, who is well intentioned, after being advised by a ‘friend’ that she can make a lot more money by suing the hospital/doc will do so… I am trusting by nature & believe (in general) that people are reasonable… but on encountering bad apples, accumulate negative baggage!

  • Diora

    And sometimes doctors order tests are not indicated and completely unnecessary. I’ve never been pregnant. I had an ObGyn who had out of nowhere decided that I needed an ultrasound – both intravaginal and abdominal – every year. I asked why, and she said “well, we don’t know why your ovaries failed”. (I have premature ovarian failure). Now, there is absolutely NO link between POF and any kind of cancer, pray show me a single study that women with spontaneous POF have any kind of extra risk, if anything, the risk is lower. There is also no recommendations for screening healthy women with ultrasounds. I switched ObGyn immediately after, but I know what is and isn’t recommended. Most women would just listen to their doctors.

    Incidentally, this was part of my deductible, so I’d have to pay the full cost which at the time was about $300. Now, I could easily afford it, but for many people that would be an issue. Not to mention that tests lead to more tests …

    BTW – before I was diagnosed with POF at 38, I complained about missed periods for years. A single blood test would’ve told them the diagnosis, OK maybe two blood tests at different times, although by the time they got around to it, my FSH was 70 and my estradiol 20. Instead the doctors ordered ultrasounds. Now, please tell me that 3- and 4- months delays in periods is a symptom of any condition that is diagnosed with ultrasounds.

  • SarahW

    I want also to encourage the doctor to appeal the insurance co’s determination that two of the ultrasounds were not medically necessary. The first trimester ultrasound in a patient that age is justified and the refusal to pay is not.

    The last one should either be paid by insurance or the cost eaten by the institution that (apparently) insisted she undergo one to be treated at the institution.

  • gzuckier

    another thing (which i made use of once); if the doctor is a participating provider, the plans will usually? always? state that you are NOT responsible for any charges for stuff he/she orders which are not properly authorized, covered, etc.

  • Molly Ciliberti, RN

    Thank you for an excellent blog.