Insurance companies' decisions sound
Sunday, May 12, 2013 10:00 PM
I want to occasionally utilize my columns to address the cost of medical care in America. Insurance companies receive a lot of criticism when it comes to denying tests and procedures. I won't try to defend some of the seemingly irrational things these companies do, but often their decisions are based on sound science based medicine.
Insurance companies have long recognized that diagnostic imaging is one area of medicine where costs have spiraled out of control. Diagnostic imaging includes tests such as CT or "CAT" scans, MRI's, ultrasound, nuclear scans, regular X-rays, etc. There is no doubt that too many of these studies are being performed (especially if you visit an emergency room). I'll try and address a few of the reasons why this occurs.
I want to start with the ordering physician. It's important to note that doctors are generally able to diagnose a patient's problem about 80 percent of the time just by listening to the patient's story. This is known as taking a good "history." This is before the doctor even performs a physical exam or orders any tests.
Taking a good history is difficult today since doctors are constantly being forced to spend less time with patients at their visits. The advent of diagnostic imaging has only amplified the problem by making history taking less important - it's just easier to order a test. Unfortunately, our health care system is geared toward getting an answer quickly, usually at a high cost, vs. getting the same answer more slowly for less cost. Getting the diagnosis faster is a good thing IF it leads to a better outcome for the patient. This is not always the case.
I want to mention sports medicine as an example of how things have spiraled out of control. Physicians depend on training and experience to be able to take a history, do an exam, reach a diagnosis and formulate a treatment plan. Most sports injuries result in conditions that will improve with conservative treatment and time. Physicians who treat athletes and are confident of a diagnosis based on the history and physical exam are still frequently asked by the athlete, parents, a coach, athletic trainer or perhaps others to immediately order an imaging test.
It's not uncommon for the following scenario to occur: an injured athlete sees "Doctor A" who recommends conservative treatment. The athlete does not improve as fast as he or others thinks he should and decides to go see "Doctor B." Doctor B has the advantage of seeing the patient after conservative treatment has failed. Often, Doctor B would have made the same recommendation had he been in Doctor A's shoes. Doctor B orders an MRI and finds something wrong that will require surgery. Doctor A is labeled a "bad doctor" because he did not order the MRI in the first place.
There are certainly situations such as suspected fractures, when ordering imaging tests immediately is indicated. If a doctor suspects a major injury to a joint or other structure it is certainly appropriate to order an MRI. It's important to note that an MRI scan gives the correct diagnosis almost 100% of the time. It's also important to note that MRI scans cost hundreds or thousands of dollars and the results may not change the plan of treatment.
While every parent, coach or trainer naturally has the best interest of their child or athlete at heart, and athletes want to get back as quickly as possible, we all have to step back and realize that giving most injuries time to improve before jumping in and getting an expensive test can be good medicine.
Dr. Roberts is a Crawfordsville physician and one of the owners of The Paper.