Monday, November 17, 2014

One Reason Why Sickcare Is Outrageously Expensive: Needless Scans/Tests

Add easy profits from needless tests to defensive medicine and no cost controls or real competition, and we have the perfect formula for waste, fraud, profiteering, bad medicine and dysfunctional, unaffordable healthcare.

Why is sickcare (a.k.a. "healthcare") absurdly unaffordable in America? There are many structural reasons which I have covered in depth for years, but one that most of us can relate to from personal experience is needless, hyper-costly scans and tests.

Even those of us who have never had a CT or MRI scan (and I hope I never will) know the drill from friends and family: practically every injury is now scanned by one device or another at enormous expense--not for treatment, as M.D. Ishabaka explains, but as defensive medicine to ward off future lawsuits or in response to patient demands.

Ishabaka (M.D.) walks us through the maze of CT and MRI by using his own injuries and treatments as examples of how our system has become unaffordable and ineffective.
"When I first got into the hospital as a medical student in 1977, MRI scanners did not exist, and the Royal Victoria Hospital in Montreal had the first CT scanner in Canada. A scan took an hour, and the images were blurry as heck, compared to modern scanners which take a few minutes and produce crystal clear images - but it was MAGNIFICENT. All of a sudden, we could see brain problems that could only be seen by operating, or doing a cerebral angiogram - a good but somewhat dangerous test (up to 3% of patients who have one suffer a stroke caused by the test). 
When used appropriately, CT scans save lots of money and lives. One example is head trauma. Most people who are knocked out just have a concussion, but a few have bleeding either around or inside the brain that will kill or permanently disable them unless they are operated on ASAP. 
In the old days, just when I was starting practice, most hospitals did not have a CT scanner. People who had been seriously knocked out were ALL admitted to the hospital for "neurological observation" - a nurse would check on them every hour to see how alert they were. 
Two problems with that: for most patients it was a total waste of time and money (and hospitalization is way more expensive than a CT scan), and for some with a bleed - it wasn't detected until too late. 
Now, when someone gets knocked out, you do a CT scan, and within 30 minutes know whether it's safe to send them home, or you need to call a neurosurgeon to operate on them - as an emergency physician working in a trauma center from 1985 - 1990 this was a REALLY GOOD THING. 
Then MRI scanners came along. They show some things really well that a CT scanner doesn't and vice versa. For example, an MRI scanner is unparalleled for showing a brain tumor. A CT is much better for showing bleeding inside the skull. An MRI scan will also show torn cartilage and ligaments in a joint with almost crystal clarity - a problem for which CT scanning is almost useless. 
So - used appropriately, CT and MRI scans are two of the greatest inventions in my medical career. 
But they are hellaciously expensive due to the fact that the machines are so expensive, and like computers, become obsolete within about 5 years - you have to pay of the multi-million dollar cost of the machine and make a reasonable profit within about 5 years. 
Let me tell you from personal experience how they get overused: In 2004 I tore a cartilage (posterior third of the media meniscus if you need to know) in my right knee. I KNEW I tore a cartilage - I had the right kind of injury, the right symptoms, and the right findings on exam. I called up an orthopedic surgeon friend of mine and asked "Do you want to operate on my knee?" Somewhat dryly he said "Well, I think I should examine you first!". 
So I went to see him. He did a regular X-ray - only $60 - pretty reasonable, and my exam showed ALL the classic findings of a torn meniscus. I told him I was ready for surgery (I couldn't run or do the martial arts classes I was taking at the time) - but he insisted on an MRI - I suspect because he was nervous about malpractice operating on a doctor in case the surgery was unnecessary - a risk I was willing to take - I would have signed papers releasing him from all liability. 
Guess what - the $1,700 MRI showed a torn cartilage, I had surgery, and my knee is 99% as good as before I tore the cartilage - so basically the $1,700 (which was about half my total operation cost) was health care money down the toilet. 
This is important: in the pre-MRI days, I would have been operated on based on my history, exam findings, and X-ray. 
Now, my back and my neck - I have had recurring problems with both. The back issue came from lifting a heavy table the wrong way. It flares up every 8 - 9 years, I rest it, use a heating pad, take some ibuprofen or naproxen and cyclobenzaprine - and it gets all better. 
In 1993, I tore something in my neck - I was lifting weights with my neck with a head harness. I was going up in weight and got to 37.5 pounds. As I extended my neck, I heard and felt a tearing sound. Idiot that I am, instead of dropping the weight, I finished the rep and REALLY heard and felt something tear. I had God-awful pain - for about a week, if I had to roll over in bed, I had to hold my head with my hands so my neck didn't bear the weight - but I got better. 
Once or twice a year it flares up, I have trouble swiveling my neck to back up my car. A chiropractor friend of mine gives me a free adjustment and it's all better within 24 hours. 
Now - here's the deal - I don't NEED an MRI of my neck or back. I'm SURE I have torn discs and/or ligaments - but I ALWAYS get better with very inexpensive meds, and a heating pad, plus chiropractic adjustment. BUT - every patient with spinal pain wants an MRI these days. ALL of them. 
The fact is - it doesn't matter a hill of beans if an MRI shows torn disc/ligaments UNLESS surgery is being contemplated. The indications for surgery are VERY CLEAR - they are loss of sensation or strength in a limb, loss of bowel or bladder control in the case of a very low back injury, or what is called "parasthesias" - burning, tingling, shock-like feelings, etc in a limb. 
The most serious of these is weakness - if a person has injured their spine, and are weak in a limb, they almost all need surgery or they will be permanently paralyzed/disabled. In these instances, and MRI is marvelous - it will show the surgeon perfectly where the problem is, so he/she knows exactly where to operate and what needs to be done. 
But for the gazillion and three patients who have pain only, and demand an MRI (and if I refuse one, they WILL find a doc to order one) it is complete and utter mal-investment of health care dollars. I have a friend who is REALLY in shape - a serious surfer and weight lifter. He injured his neck in a surfing wipe-out in his early 30's and his right triceps became weak. He asked me what to do and I told him to get an MRI and see a neurosurgeon. 
Well, he didn't want to, so he tried all kinds of useless remedies - he kept coming to see me (as a friend, not as his doctor) - and I could see his weight-lifter's triceps shrinking away to nothing. Finally I got him to see a neurosurgeon friend of mine, an MRI was done showing a ruptured disc pressing on (and slowly killing) the nerve that activated his right triceps - he was operated on - and ALL his strength came back. 
So - bottom line - in appropriate circumstances, CT and MRI scans save lives and limbs - they are wonderful tools. However, my rough estimate is that probably around 90% of MRI scans and 80% of CT scans done in the USA now are a complete waste of time and money. 
The real point about scans - and so many tests - is you treat the PATIENT - not the scan, or the test. Tests are just an aid in determining what is the best treatment for the PATIENT. 
The corollary to this - and what it is SO HARD to convey to many patients - is that if the results of a test will not change the treatment - there is no reason to do the test. A classic ER example is an injured small toe (the big toe is different). It DOESN'T MATTER if the toe is broken or just sprained - the treatment is the same - taping, ice and elevation for 24 hours, rest, and mild pain medication. Try telling an injured patient that you are not going to order an X-ray of their toe - they will complain to the hospital administrator, and you will be lucky if you are not fired."
Thank you, Ishabaka, for the detailed explanation. I should also add that scans costing thousands of dollars each in the U.S. are available in other countries with the exact same machines for a fraction of the cost in the U.S.

As I noted in Sickcare Will Bankrupt the Nation--And Soon (March 21, 2011), Pittsburgh has as many MRI machines as the entire nation of Canada.

Why is this so? Studies have found that a doctor who owns his own machine is four times as likely to order a scan as a doctor who doesn't. Garsh, I wonder why.

Add easy profits from needless tests to defensive medicine and no cost controls or real competition, and we have the perfect formula for waste, fraud, profiteering, bad medicine and dysfunctional, unaffordable healthcare.

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