The decisions doctors make - what tests to order, what procedures to recommend, and what medications to prescribe - are often influenced by factors other than good medical care. Patient expectations and defensive medicine sway these decisions, as do the economic interests of hospitals, doctors, medical equipment manufacturers, and pharmaceutical companies. If we were able somehow to control medical decisions so that these nonclinical factors played only a minimal role, we could both improve care and cut costs. It may sound simple, but limiting excessive care and basing medical treatment on science tempered by compassion has proven very difficult to accomplish. So difficult, in fact, that Congress in its ongoing discussions on health care have chosen largely to confine the debate on how to finance our overpriced, underperforming medical system, and have ignored the more politically difficult question of how to improve it.
Recently, several studies have been published which can serve as models to show that improving quality and controlling costs can be simultaneously accomplished. In December, 2009 two articles were published in the Archives of Internal Medicine discussing the increasing use of CT scans and the possible harmful effects of the radiation exposure that result from that test. CT scans are a computerized series of x-rays that provide detailed views of different parts of the body. These scans have been very helpful at diagnosing and monitoring diseases and represent such a significant medical advance that the inventors of the CT scan were awarded the Nobel Prize for medicine in 1979. Over the past three decades, their use has been increasing yearly. In 1980 about 3 million CT scans were done in the US but by 2007, 72 million CT scans were done.
Most CT scans are performed for valid reasons but millions are carried out for only marginal indications. These additional scans are not just costly, but they present potential medical problems. Each CT scan, x-ray, mammogram, PET scan, and radionucleotide cardiac stress test exposes a person to radiation. Radiation from diagnostic tests can cause cancer with the risk of developing cancer dependent on the cumulative lifetime radiation exposure. Each and every additional test increases the possibility of a fatal disease. Investigators from the National Cancer Institute estimate that CT scans done in 2007 alone would cause 29,000 malignancies and 15,000 cancer deaths! If there were some way that we could decrease the number of CT scans (and all other diagnostic radiation exposure) without compromising quality we could both improve overall medical results and also cut costs.
In the January 2010 edition of Connecticut Medicine the use of CT scans in the emergency room of Norwalk Hospital to diagnose a pulmonary embolus (PE), or a clot in the lung, was reviewed. PEs are potentially fatal and are responsible for 50,000 deaths annually in the US. It is a diagnosis physicians do not want to miss for when found, effective, life-saving treatment is available. The experience in the ER in Norwalk Hospital in their approach to diagnosing PEs likely represents the pattern in ERs across the whole country. Although there are a variety of ways to diagnose pulmonary emboli, from 2000 to 2005, CT scans became essentially the sole test employed in the Norwalk emergency room entirely replacing all other tests. That short time span saw a 14-fold increase in CT use in the evaluation of patients for PE. Of the scans that were done, ninety three percent were normal and only seven percent were positive for the clots. For the overwhelming majority of patients with normal CTs, these extra scans were not only unnecessary, expensive, and avoidable but, because of the added radiation, presented a real risk for the future development of cancer. Again, this type of suboptimal and expensive medical care is not unique to a single hospital but represents nationwide trends.
There are well-documented ways, however, to avoid the excess CT scans and still not miss the diagnosis of a PE. Predictive models have been published in the medical literature, using clinical information including the patient's medical history and physical examination, which can determine a patient's likelihood of having a pulmonary embolus with a high degree of certainty. Those ER patients with a low likelihood could have a simple, inexpensive, risk-free blood test that would exclude a pulmonary embolus. Those with a greater likelihood could have a V/Q scan, a less expensive test than a CT that also exposes the patient to less radiation. CT scans would be reserved to the occasional patient for whom the V/Q scan was not diagnostic. This approach could both save money and improve care.
So why isn't this tactic already in place? Because the forces that drive American medicine demand otherwise! Doctors order the CT as added protection against malpractice suits. Radiologists and hospitals encourage their use because of the higher reimbursement rates third parties pay for the CT scans. And patients like the more advanced, more involved test. It is time that the less expensive approach with fewer dangerous side effects becomes the standard way to diagnose PEs. Pressure needs to be exerted to limit CT scans unless really indicated and doctors who follow well accepted predictive models should be protected against malpractice suits.
In other areas of health care where such similar models are already available but are similarly ignored, cost-effective medicine should become the accepted way to determine practice policies. Where not available, cost-effective models need to be studied and created. Adopting accountability in health care is an important means to control America's rising health costs while improving the quality delivered.
The federal government is allowing discrimination to continue in regards to access to long-term care for people who otherwise qualify for Medicaid. The mental health parity law did not repeal the Medicaid Institutes of Mental Diseases (IMD) Exclusion nor has its repeal been crafted into the health care reform bill currently under negotiation.
This has the effect of denying care to the people who need treatment the most and are less able to pay for it. That the states have interpreted the fact that Medicaid will not help them subsidize long-term care for people debilitated by brain disorders, to mean that people who have brain disorders never need long-term care is an important distinction. However, that is exactly what it has amounted to.
Please read this article: Mental Health Parity Law Allows Discrimination to Continue http://www.opednews.com/articles/The-Mental-Health-Parity-L-by-Ilene-Flannery-Wel-100211-135.html
and Mental Health Parity, Obama Style http://www.huffingtonpost.com/dj-jaffe/mental-health-parity-obam_b_443714.html
Please also go to the Treatment Advocacy Center website to learn more about the IMD Exclusion. www.treatmentadvocacycenter.org
But for"Real" Health Care Reform, we better takr a good look at the big picture and address ALL the unnecessary and rigged costs:
Americans are overcharged more than twice the going rate for health care (and die sooner).
Let's eliminate the Insurance anti-trust exemption which enables insurance companies to charge Americans any random price they want.
Let's get rid of the anti-competitive deals drug companies use in order to charge Americans more than anyone in the world.
Let's eliminate all other deals for health interests that rig health care costs above the market price.
The rest of Americans have to compete for a living, so why do health care actors think they are entitled to make anti-competitive deals to just take whatever they want from the wallets of Americans without competing for it?
How about doing something simple but effective like pass a law that says American drug companies can not sell drugs in other countries for less than in America?
Americans pay 3 to 5 times as much for drugs as people in other countries.
We pay ALL the R&D cost for the whole stinking world. That's why people here want to get drugs from Canada. They’re the same drugs made by American drug companies sold to Canada (and everywhere else but in America) at 60 to 80 percent off!
Every other countries cost would go up a little and our costs would go down a lot if the R&D costs were spread evenly.
Why not give Americans a fair deal from drug companies in the Health Care Reform?
Even the GOP would HAVE to support this. Their base would kill them if they did not, because they always say, America First.
Can you use your expertise to lower the cost of healthcare in your state of Connecticut?
And then in the neighboring states of the Northeast, where healthcare cost per patient is on average twice what it is in Midwest states?
DG
Universal Government Health Care Could Save $1Trillion Dollars from the $2.6Trillion Spent Last and No One Would Be Left Without Care.
Dual separate systems coexisting; one public the other private could provide health care choices for everyone.
Everyone choosing free government care, paid for with a national sales tax instead of insurance, can have it regardless of age, financial circumstances, or pre existing conditions, there will be no restrictions, no insurance, no co pays, and free period.
Private employers who choose government care for their employees will no longer have to pay for or be involved with health care in any way.
States could get out of the health care business by off loading all of their health care costs and obligations to the new government NHC.
The federal government’s entitlement disasters of Medicare and Medicaid could easily be salvaged without bankrupting the federal government by using a national health care system to deliver high quality care and medications through government systems at a fraction of the costs now being devoured by private systems.
Seniors using public care will receive it free; no more insurance payments, donut holes or copays.
Everyone who receives government funded health care from any source anywhere in the US would receive their care from NEC.
The second system would be a Private Option; no public funding would be paid to private insurers or providers and all care would be delivered from private hospitals which would not be subjected to any government mandates.
Radiology professionals understand better than anyone the pitfalls of examination through excessive radiologic procedures. To make blanket statements, such as the quote above, is irresponsible in it's portrayal of professional greed taking priority over a patient's health. Thankfully, most of the men and women I've worked along side during my career do not share your view. Admittedly, the best way to image certain pathology often includes technologies that are of greater risk, but ultimately it's the ordering physician's responsibility to determine what's best for his/her patient....including whether or not imaging is at all required.
Medicine today requires everyone involved to make sound, educated decisions regarding treatment of patients. All too often, though, defensive practices or just doing what's most expedient takes precedence over thoughtful, precise care. There are many reasons for this, some for which the medical community must assume responsibility. Other realities also play important roles in an industry behaving the way it does. From health insurance corporations to lawyers to medical manufacturing to big pharma, no one is innocent when it comes to the calamity awaiting us if nothing is done. This article really adresses one aspect of a much more complex failure....one our government is clueless about fixing.
Infection rates and medical errors--never discussed. Rates are the same as in 2000, when the light was first turned on these two issues.
And let us not forget---there is absolutely no incentive for physicians to limit what they order, and the last time I checked, patients could not order for themselves. It has been my experience that physicians do what is best, easiest, and fastest for them. A recent experience with my 80-year-old father who was on a medication causing problems just re-confirmed this belief. Rather than a trial off the meds I was told I was crazy, so the CT was done--normal, the labs were done--normal--the Gastroenterologist was seen--normal, finally--off the med--cure. The stress, co-pays, the radiation, all not needed. But my 80-year-old father believes his doctor has his best interest at heart--so he listens.
For radiologists, the situation is even more complex. For them to recommend more frequent, more expensive, and more sophisticated tests not only provides them higher reimbursement, but gives them added protection from possible malpractice suit. This saturation radiography happens every day in clinical practice.
Reimbursements in medicine need to be aligned with sound, cost-effective care to minimize needless and excessive care to improve quality and to cut costs.
DG