Who's to Blame for Healthcare Costs?

My sister in law was asked to have a hs-CRP level checked as part of her annual visit to her primary care physician. She is in her mid forties, mildly obese and has hypertension. The level came back elevated. Rather than repeat the test, her physcian refers her to a cardiologist who has her scheduled for an echocardiogram and a stress myocardial perfusion study. She is asymptomatic. The liklihood that she has significan multivessed coronary heart disease to the extent that she would benefit from revascularization therapy is extremely small. Whether or not the perfusion scan shows any perfusion abnormality, she may also undergo angiography via CT and or catheterization. After spending thousands of dollars for the testing, the end result will be the same even if her CRP had not been checked. Loose weight, exersize and control blood pressure. Some physicians like my sister in law's primary order innappropriate studies out of fear of litigation. Others, like the cardiologist in this case, order tests that will generate income. The patient most often is out of the loop and will follow the doctor's orders. Physician's have failed in the attempts to police themselves, now the government has to step in and has no choice but to cut reimbursement rates. We likely have no one to blame but our selves.

But I'm Feeling Better Doc!

Here's a good one. The patient was referred to a cardiologist due to chest discomfort and a stress echo was ordered which was normal without any evidence for coronary artery disease. When the patient next follows up with the cardiologist (his PA of course) he tells her that his discomfort is basically gone as his primary physican started treatment with a PPI. Rather than make the obvious assumption that the patient is being appropriately treated for dyspepsia and leave it that, they schedule the patient for a coronary CTA! Obviously if a stenosis is felt to be present, this guy will then get a diagnostic catheterization despite the fact that his symptoms have resolved with treatment for dyspepsia and he did well on his exercise stress echo with good exercise tolerance, normal LV systolic function and no evidence for ischemia. Guess who owns the CT scanner in this case? Greed on the part of the physician is another huge reason for the costs of health care. I see examples of this every day, even with my own partners. There absolutely should be appropriateness criteria and all health care providers should be forced to comply.

Cost of health care in the U.S.

What's driving up the cost of healthcare in the U.S.? We are. There is a tremendous amount of excess being performed in hospitals due to lack of thinking and diagnostic skills with heavy reliance upon objective testing and fear of litigation. Example: a 57 year old gentlemen with treated diabetes and HTN presented to our emergency department with the complaint of chestpain that had been persistent for > 12 hours. The pain was positional, worsened with a deep breath and he was very tender to palpation over the left anterior ribs. He was monitored in the chestpain unit overnight, serial biomarkers were drawn and normal, ECG was normal, Chest xray and a chest CT were performed and unremarkable. NTG was given without a response. Even with a diagnosis of "musculoskeltal" chest wall pain, I was called to come in and do a formal cardiovascular assessment on the patient before he was discharged. There was some surprise when I decided against any objective evaluation for coronary artery disease. In my day, the history and physical along with simple testing like ECG was enough to triage people in the acute setting. Every patient with chest discomfort does not need a CT scan, and myocardial perfusion study. You have to wonder if the excess radiation exposure from some of these studies might not have something to do with the incidence of soft tissue malignancies like breast CA in the population.

You need a heart cath!

Often a patient with a suspicion for coronary heart disease will have a non-invasive evaluation like a stress echocardiogram as an initial objective evaluation. If significant abnormalities are present a cardiac catheterization for possible revascularization therapy will be pursued. Obviously it is financially advantageous to have an abnormal non invasive study that will justify a follow up catheterization. The problem is that these stress tests, especially stress echocardiograms are very subjective. There is a cardiologist in my community who will acutally choose images for the final report on a stress echo that are either off axis or poor quality so that he can interpret the study as abnormal and subject the person to further testing even if it actually is a normal study! When the cath comes out normal, he tells the person that it was a good thing that he did the invasive procedure to find out for sure that the coronaries look okay and they are usually very happy to learn that they don't need bypass surgery. (Had he been honest in his interpretation of the stress test, the wouldn't need bypass surgery or the cath that he just did for the money.)

An MRI? I ordered a sleep study

I referred a patient for a sleep study on the suspicion that his daytime somnolence and history of snoring might indicate sleep apnea, a treatable condition. What I received was a report of a consultation performed by the physician at the sleep clinic and his ordering of the same exam I had asked for. This upset me a bit but I accepted it as a sign of the times and the economy. In the medical field as in every other area of business, everyone is trying to make a buck and requiring a consultation prior to testing is that medical group's policy. I would require that I meet and examine a patient before preforming an outpatient catheterization procedure. (That's because it is an invasive technique with true risks, not just watching someone sleep!)
What really pissed me off, however, was the part of the consultation report where the physician examined the patient for signs of spinal stenosis due to his history of lower extremity pain and recommended an MRI scan! How convenient that his group happens to own and operate an MR scanner. Obviously this is a case of attempt for self referral and taking advantage of the patient. All I wanted was a simple sleep study but I got a sleep physician's consultation and recommendation that he return for an MRI to evaluate possible neurogenic claudication!
What the F---?

Your patient is ready

Another small rant before I continue my story. "Dr. Miller, your pt. is on the table and ready!" This is the page I got this morning while making rounds on the inpatients in one of our hospitals. I apparently was supposed to to a cardiac catheterization procedure on one of my partners patients who had never spoken to me about this gentleman and the indications for the procedure let alone let me know it was being placed on my schedule. Now granted, a diagnostic coronary angiogram is not a major procedure, but knowing that it was ordered on an 84 yr.old man with exertional chest pain and syncope and an echo showing moderate/severe aortic stenosis would have been useful information when I walked into the lab. Do you think the patient and his family knew that I was walking in "blind"? Of course not. To save face I absolutely lied to them telling them I had discussed his case with my partner in detail and understood exactly why the procedure was to be done and that I had agreed with his recommendation. My partner is a non-invasive cardiologist and therefore does not perform catheterization procedures yet he is the person who obtained informed consent on this elderly man. Is that right? How can he get permission to do an invasive procedure on a person that he doesn't perform and that will be done by another individual they haven't met while he's in another state at a conference?
I understand that the path of least resistance for my partner after seeing a patient like this in the office is to simply check the box that says diagnostic left heart catheterization/coronary angiography on our discharge router and move on to the next room. But what about the patient involved? Shouldn't they get just a little more personal attention and know that if another provider is going to be involved in their care that they were well informed? Wouldn't my partner want to meet the person doing this same procedure on his wife or mother? This guy didn't put up any fuss so he never had a chance. I felt like such a fake and almost as if I were victimizing someone who due to his age and perhaps limited sophistication was being taken advantage of.

Why Me?

Okay, so why did I get started in the medical field? I'm not really sure but I do know that it was not my lifelong dream to become a doctor. I remember being terrified of going to the doctor when I was young, especially afraid on needles and such. I also recall feeling extremely queasy on the couple of occaisions I had to go to the hospital to visit a relative. My father was a veterinarian but I had no interest in watching him at work and even watching him do procedures or surgeries on small animals would often leave me feeling kinda faint.
I think my parents, especially my mother, wanted a doctor in the family and they choose me as opposed to my brother or sister. If I ever had to pick a favorite subject in school, I like alot of kids, would pick science. But I think I was thinkin more about rocket ships and outer space, not taking care of chronically ill elderly people. None the less, when I got to college (which was expected of all of us), I basically started in a "premed" program and never looked back or ahead. Before I knew it, I had an old lady as a counselor who had me registering for the MCAT and applying to medical school. I didn't have any other plans, and didn't like factory work, so I simply just followed her advice and went with the flow!!