Have you had the experience of waking up with back pain? When you went to get out of bed you couldn’t? Finally rolling out of bed you made your way to your computer and checked on the Internet for a diagnosis. Your conclusion? A herniated disc. The website you consulted told you that you needed an MRI of the back. You called your primary care doctor for an appointment, shared your symptoms, and asked for an MRI. But he refused! What’s with that?
It is just the tip of the iceberg. Sophisticated testing can account, by itself, for consuming nearly ten percent of the health care dollar. Initially when Insurance companies were looking for the “low-hanging fruit” to pluck, they targeted such testing. And they continue to monitor its usage.
Take the example of your back pain. While it is true that testing could determine whether your pain is due to a slipped disc, the reality is that whether this is the cause or not, whether anything is to be done for it, or not, in the majority of cases the pain will resolve on its own within six weeks. Only if it doesn’t would a surgeon consider operating. And only if an operation was necessary would an MRI be useful, to target the area needing attention.
So the only use for the MRI, earlier than that would be to satisfy the curiosity of you, the patient, or that of your primary care physician. And quite frankly, the health care system can’t afford to pay to satisfy your curiosity. So the MRI gets postponed.
Another reason for excessive testing, besides satisfying curiosity, is confirming a diagnosis. With an increasingly litigious society, doctors want to be able to prove, beyond a shadow of a doubt, that they have made the correct diagnosis and instituted the correct therapy. But this can be carried to the extreme. For example, someone with chest pain sees their primary physician where an EKG is done. It’s unremarkable but the physician is still worried so he refers you to a cardiologist. He/she is not satisfied with the EKG you provided to them so they repeat their own. There may be a legitimate reason for doing so (eg. they were concerned about the placement of the chest leads) but just as likely they are repeating it because it provides an augmentation to their income.
They proceed to order a stress test, followed by a nuclear stress test or a cardiac ultrasound stress test. Then they may order a cardiac MRI or even angiography. All to confirm that what the history suggested or the stress test revealed, was indeed accurate. While it could be argued that each test provides another bit of information about the status of your heart disease, it comes with a substantial cost. And as resources dwindle, the ability to provide confirmatory evidence may be sacrificed.
This is not to say that all testing is bad. But as some of the genetic testing becomes available, which can predict what ailments you might be at risk for, the price tag continues to rise. And knowing that Alzheimer’s might be in your future, when we have no effective treatment for it at this point, does nothing more than increase your anxiety, at an exorbitant price.
However insurance companies have tried to take this a little bit too far. While there are expensive tests out there, of dubious value, some basic testing probably still has a place. There has been a lot of controversy about Pap smears and PSA. Whether they are useful screening measures. Or mammograms. The medical literature is still ambivalent about our current screening strategies. Are we just increasing costs still further by pursuing false positive results? But the expense of these tests pales in comparison to some of the more complex tests. And they may help identify a problem when it is still in its nascent form. Still easily treatable.
But here is where a discussion with your doctor is important. But, of course, as was mentioned before, without adequate time to have that discussion. So how are you to get what is necessary without getting more than you need? This remains a bit of a conundrum but we will provide some alternatives in some of the following articles.