Wednesday, April 04, 2012

Common Sense Prevails As Doctors' Group Calls Upon Profession To Stop Over-Ordering Tests; Procedures

The MSNBC headline is misleading. Doctors aren't calling for an end to 45 procedures, including PAP tests in certain circumstances, or chemotherapy for those suffering from terminal cancer. They're calling for doctors to utilize procedures and drug regimes when the circumstances call for it - based on the science.
Nine medical societies, including the American Society of Clinical Oncology and the American College of Cardiology, representing nearly 375,000 physicians are challenging the widely held perception that more health care is better, releasing lists Wednesday of tests and treatments their members should no longer automatically order.
The 45 tests and procedures considered to be overused include:

  • Repeat colonoscopies within 10 years of a first test
  • Early imaging for most back pain
  • Brain scans for patients who fainted but didn't have seizures
  • Antibiotics for mild- to-moderate sinusitis unless symptoms last for seven or more days or worsen
  • Stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present
  • PAP smears on women younger than 21 or who have had a hysterectomy for a non-cancer disease
  • Advanced imaging or bone scans in patients with early-stage breast or low-grade prostate cancer
  • Bone scan screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors
  • Routine cancer screening on dialysis patients with limited life expectancies
  • Chemotherapy for sickest cancer patients

Dr. Christine Cassel, president of the American Board of Internal Medicine, said the goal is to reduce wasteful spending without harming patients. She suggested some may benefit by avoiding known risks associated with medical tests, such as exposure to radiation.
Doctors may be prescribing these procedures or ordering tests because they're practicing defensive medicine - ordering tests so that if they miss something they can point to the test (and the ordered test) to show that they didn't commit medical malpractice. That's something that the article doesn't address.

The article does tangentially address the fact that some doctors and medical groups may benefit economically from ordering tests and procedures, such as EKGs, even though they aren't always necessary. It notes that insurance companies would have a hard time filtering out unnecessary tests from those that are prudent and necessary:
Insurers will certainly take a close look at the recommendations, but what they do may be limited. That's because most of the questionable tests and treatments in the lists don't particularly stand out in the avalanche of bills processed daily by insurance companies.

Take a recommendation for no annual EKGs for low-risk patients with no heart symptoms. Dr. John Santa, director of the Consumer Reports Health Ratings Center, said he used to routinely order EKG's when he was a general adult medicine practitioner. EKGs cost $50 to $60. A medical assistant would do the tests, and it would take Santa just a couple of minutes to read them. Yet 2 percent to 3 percent of his income came from EKGs, enough to make a difference in a tight year.

"It's very difficult for an insurance company to tell the difference when an EKG is being used as a diagnostic tool and when it is being used as a screening test," said Santa. "It would probably cause more trouble for insurance companies."
However, doctors and patients need to understand that not everyone benefits from a one-size fits all approach.

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