Perverse incentives push physicians to order ineffective tests

When I meet a new patient, I’m frequently astounded by the health care he has received. I’ve met patients with absolutely no cardiac symptoms who have been receiving EKGs every six months for years. I’ve had patients brag to me about their annual executive physicals in which myriad tests including treadmill stress tests and chest x-rays were routinely performed. Patients get head-to-toe CT scans under the mistaken hope that they might save their lives by finding something. I’ve seen patients with no family history of colon cancers have colonoscopies every two years, because they really want to make sure that they don’t get colon cancer. Some patients do the best they can to be tested for everything.

In the absence of appropriate indications, all these tests are not only without value, they can be harmful. Even in perfectly healthy patients they can yield abnormal results simply through error. (These results are called false positives.) These results then have to be pursued with more invasive tests that can have complications and risks. This isn’t just a theoretical risk. I’ve seen patients harmed by tests that should never have been done.

Doctors are quick (and correct) to roll their eyes when patients take various unproven alternative medicines. When they take echinacea for their coldspop their multivitamins, and take black cohosh for menopausal symptoms. Patients should know that what they’re doing is unproven. But it occurs to me that doctors are much less critical when unproven or ineffective interventions are pushed by our colleagues. An unindicated stress test is every bit as unlikely to help a patient as a multivitamin, but potentially riskier. After all, a false positive result from a stress test may lead to an unnecessary angiogram, a risk that the multivitamin doesn’t carry.

The incentives that perpetuate the first type of ineffective medicine — the herbs, supplements, and vitamins — are obvious. Suppliers want to sell their product. They label and advertise their product with messages that fall just below the threshold for fraud, and patients interpret these messages to mean far more than they do. Eager to find something effective for what is frequently an untreatable problem (like a cold) patients understandably flock to these ineffective remedies.

But ironically, ineffective tests and remedies prescribed by physicians have even more perverse incentives. At least the patient has to pay for her own echinacea and her own vitamins. The pointless EKG and stress test are covered by insurance! In a system in which tests are covered and the prices are fixed by the insurance company, the incentive is to deliver as many tests as possible. The doctor doesn’t lose anything if some of those tests lead to needless anxiety and further invasive testing. The patient doesn’t think to ask questions about the proven risks and benefits because he’s not getting the bill. The incentives do not reward achieving health, or preventing disease, or maximizing patient satisfaction. They reward delivering services. And we’re surprised that the result is the delivery of lots of services with no value.

Escaping the insurance system makes it easier to see the problem more objectively. I get paid by patients to listen to them and give them advice. I don’t get paid more if I order a test, and I also don’t get paid less. And I’m not paid by anyone but the patient. So I can actually take the time to educate the patient about the risks and benefits and figure out if she really wants the test. The net result is that patients pay me more so I can make sure they get more education and less health care.

I’ve written before about how our current health care market broke and how I believe it could be fixed. I think insurance coverage of routine care is a major flaw in the current system. We are currently expending enormous resources trying to insure everyone. If, as I believe, insurance is the problem and not the solution, the results will be even worse than the broken system we started with.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • Deceased MD

    I have seen pts who have had prior tests ordered in large academic centers and no follow up or call back to the pt to indicate what the expensive test showed. They are lost. But a lot of money has been spent on the test.
    What is most concerning as this article implies is that there is little thought put into pt’s diagnosis in many settings. it’s just a matter of ordering a lot of tests. There is pretty much no collaboration for anyone that needs it. That is a by gone age.

    • dontdoitagain

      I recently had one of those stress tests. ($3000 where I went) I tried to tell the doc that my symptoms weren’t brought on by exercise. They happened when I stopped exercising. They happened when their damnable arbitrary “good” blood pressure readings got down to around 100/60. My anxiety over the pain grew worse, you know, buying a bp monitor and self adjusting my Lisinopril (in defiance of the doctor) Whenever I saw that number I knew I was going to have trouble.

      Naturally the stress test showed nothing. “Low risk” for heart attack is what the paperwork said. I had to change to a doctor who owns horses like me so we had a tenuous connection. Here I am explaining to the new doc that I had “non-cardiac” chest pain, just like the test showed. I wanted help with that, it was extremely painful, it was exhausting, it occured frequently even waking me up at night, I thought maybe thyroid? I ended up with a stent. I’m alive because of my horse in an odd way.

      • querywoman

        Did the stent help?
        Too many doctors rely on tests too much and not symptoms!

      • Deceased MD

        I am so glad you persevered. That is really awful and I am afraid it seems all too common. Sounds like you had a horse not a zebra–meaning it was not uncommon your procedure or diagnosis that saved your life. It is hard to imagine that no one would proceed further with a work up for chest pain. This is bread and butter medicine. So glad you are here and can tell us your story. you might want to consider writing a piece on here about your experience. I for one would be interested.

    • querywoman

      Ha! It doesn’t have to be a large academic center! My minister’s wife had some kind of biopsy some where in her tummy over 10 days ago and they still haven’t heard a word!

      • Deceased MD


        • querywoman

          Duh! I checked. She works for a university system and was using a university-associated hospital! After about ten days, finally got all results. No malignancy, but maybe something else. She doesn’t want to say too much about it.

  • Margalit Gur-Arie

    Medicare pays something like $16 for an EKG. Is that enough of an incentive to buy a machine and use it to systematically harm patients?
    BTW, I know people who don’t even bother with billing for EKGs….

    Not sure this has as much to do with insurance as it has to do with practice type and physician employment status.

    • Lisa

      My pcp has an ekg machine. It takes his about nurse five minutes to perform one. That is $320/hour. I am not on medicare and I have no idea how much he bills my insurance for them, but I have liked the fact that I could get one at his office as part of a pre-op physical and not have to go to the hospital to get one.

  • LaurieMann

    I think some annual tests make sense, like blood work. But I have started to see some pushback on other kinds of tests. After months of stomach pain, I had an endoscopy and was diagnosed with an ulcer about six weeks ago. The doctor put me on meds and scheduled a follow-up endoscopy for May. The insurance company refused to pay for the follow-up. As my symptoms were much improved after a few months of dietary changes and a few weeks of meds, I’m fine with not having that test again. If I was still having symptoms, I would probably have contested it.

    • querywoman

      I’ve been taking thyroid pills since my teens. In my thirties, I was getting certain blood work annually along with my thyroid test. In spite of ever rising blood sugar, I did not get diabetes medicine until I had a 325 fasting sugar.
      Yet, the docs wanted to discuss my blood pressure all the time and one suggested a mammogram (I must have been 37.)

  • Steven Reznick

    In the President’s talks on the Affordable Health Care Act he often cites the Mayo Clinic and Cleveland Clinic as examples of the gold standard of medicine. There is no question that these are superior centers’ of Excellence. They both offer ” executive physicals” that include batteries of tests and exams costing well over $5000 per exam. If the ” gold standards” of care are performing these multi test , multi radiation screening procedures how can you expect others to not believe this is the way medicine is meant to be practiced?
    There is no answer to the question of the value of a screening test. Just last week I had a patient with minimal cardiac risk factors show up in the hospital with acute appendicitis. The ER staff ordered a EKG which showed a Complete left bundle branch block. Since he had no outpatient symptoms I had not obtained an EKG on this patient in well over a year and that EKG did not contain the conduction system abnormality. I certainly wish I had found this EKG change electively as an outpatient and worked it up so that I didnt have to send this patient off to emergency surgery not knowing if he was at major risk for a cardiac event or if he had recently had one?
    Dr Fuchs makes a fair argument against unnecessary testing for financial gain. The problem is that there needs to be a better balance between the minimalist recommendations of the USPTF and the blue plate specials of the Mayo Clinics.

    • buzzkillerjsmith

      Executive physicals. Beautiful. But you and I and everyone here know that that is not how medicine should be practiced, Mayo or no Mayo.
      I once saw a billboard on Interstate 95 in Philadelphia. It was a radiology group advertising full body CT scans. You can never be too careful….

  • Thomas D Guastavino

    There is nothing wrong in a patient asking about tests. I invite the dialog. Most of the time patients accept my explanation. On those occasions when they don’t I ask if they would like a second opinion, even offering to arrange it for them. Its when patients go behind my back that I do not find acceptable.

    • querywoman

      And I keep forgetting to tell my endocrinologist, who loves my self-responsibility, that he needs to occasionally test my iron in his regular tests because twice in my life I have gone into anemia.
      I had a 2 day hospitalization in January for anemia. Dya think they routinely check iron levels at such a time?

      • Thomas D Guastavino

        Do you mean testing your iron levels or your hemoglobin and hematocrit ? The latter is routinely tested, the former is rarely tested.

        • querywoman

          I’m not sure since I’m not a doctor. The lab tech said he needs to add a CBC to the order. I’ll fax him some sugars ina few days and let him know about the anemia twice in my life.
          I used to always have excellent iron.
          Sometimes docs do need to be told things.

        • querywoman

          The endo and I have a near magical connection. I threw this in as example of a common illness and a common test. I also have a general internist, who treated me in the hospital.
          I know you will agree he needs to know aobut it. It’s a good example of something that just hasn’t been brought up. I gave him more of my history last week.
          He asked me where I was treated for pneumonia. It was in “his” hospital, and I think he is going to pull the reocrds and look at them.
          I am hypothyroid and diabetic. I have lost 70 lbs from getting off insulin and going on the Victoza he prescribed. Unfortunately, I had much more serious pneumonia in 2012 shortly after I went on the Victoza.
          It wasn’t as bad two months.
          I think I am his best results, period, but, needless to say, he wasn’t a happy camper about the 2nd flu/pneumonia incidence.
          You doctors, unfortunately, have some control over flu/pneumonia now, but you still can’t keep it from wiping out and often killing patients and yourselves.
          Do you think you will live long enough to see flu eradicated? Can we hope for it?

  • querywoman

    Very good for you! So the “horse doctor” practiced symptom-based medicine on you?

  • querywoman

    Right on! Symptoms are mental illness.
    Glad you found the horse doctor!

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