Having worked at both community hospitals and major medical centers, the issue of ultrasound in pregnancy has revealed itself to be more complex over the years. As a resident, I worked with an obstetrics office that only scanned their own patients who had private insurance and would send uninsured or Medicaid patients (often with a high risk of inadequate prenatal care) to the hospital late in the day to be scanned after their office had closed. While seemingly ethically deplorable, this was business as usual in that community. In the affiliated community-based obstetrics residency, obstetricians-in-training did not learn how to scan with all in-hospital ultrasounds read by radiologists who were happy to benefit from those fees. Since the providers could not scan patients themselves, patients with appropriate prenatal scans would often get full repeat ultrasounds prior to delivery if they came to the hospital at a time in which reports from the performing facility. The massive expense of this unnecessary imaging was never measured or regulated.
The other thing that I noticed is that women would often arrive at the imaging center with a diagnosis of “large for gestational age.” These fetuses were usually normal or even small, but it became clear that this was a trick used to improve recovery for billing, as some insurance companies in many regions will not pay for imaging that is not indicated.
Regarding the issue of paying cash for ultrasounds performed outside the medical setting simply to get “keepsake” images, this practice is discouraged by many professional physician groups including the American College of Radiology and the American College of Obstetricians and Gynecologists. Likewise, pregnant patients should understand that sonographers ought not provide unnecessary imaging in the emergency department for reasons outside of the declared emergency such as gender determination. An ultrasound is usually indicated for bleeding during the first trimester, but the goal of imaging in this stage of pregnancy is not to assess fetal anatomy.
Most larger medical centers have obstetricians with specialized training known as maternal-fetal medicine who interpret second and third-trimester ultrasounds in high-risk patients leaving newer radiologists untrained in this skill.
I witnessed an unfortunate “tale of 2 patients” with fetal hydronephrosis (too much urine retention by the kidneys) in medical school while shadowing a maternal-fetal medicine specialist that highlights the stress that misinterpretation of an ultrasound can create. Both patients were referred to an onsite genetic counselor based on the premise that this abnormality can be seen with Trisomy 21 (Down’s Syndrome). The genetic counselor sessions went markedly differently for both patients. The first patient was in her 30s and seemed well informed and educated. The counselor told her of the findings, and when the patient asked what the real likelihood of Down’s Syndrome was, she was told that the risk was not that great. She and her husband thanked the counselor and left without additional anxiety. The second patient was much younger and of a less extensive educational background. After calling all members of her immediate family to come to the counseling appointment, everybody in the room broke into tears when the possibility of Down’s Syndrome was raised. The counselor mentioned an amniocentesis as well as its associated risks, and this only amplified the hysteria in the room. I am not sure that any of it was necessary. Both babies turned out to be normal. What’s more, both women were near the end of pregnancy and were going to deliver anyway. I will never know if the offering of an onsite genetic counselor session for this finding was medically necessary or simply a billable service.
An ultrasound performed on an outpatient basis early in the pregnancy and in the 20-week range are appropriate to assess most fetuses. In most pregnancies that progress normally, these scans are probably sufficient. I worry, however, that our thirst for medical imaging is becoming less quenchable as time goes on. The use of fetal MRI is now ramping up to the point where government insurers are questioning its true ability to provide results that change management during pregnancy.
What has happened over time is that the system pushes back on excess medical imaging. Reimbursements get slashed, and departments must perform more exams to recover the same revenue in the face of increasing costs to replace the equipment. Somehow in the middle of it all, the administrative puppet masters behind the scenes pull strings to maximize monetary recovery. I wonder if our ethics are being compromised along the way.
Cory Michael is a radiologist.
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