Myth has become fact with cervical cancer (cc), it was never a major killer of women in the developed world, it was a fairly rare cancer. (and it was in natural decline before screening even started) There are also, no randomized controlled trials for pap testing. The lifetime risk of cc is 0.65% while referral rates for colposcopy/biopsy are MUCH higher. (77% here, similar in the States) Over-screening leads to lots of false positives and potentially harmful over-treatment for no additional benefit to women. If you look at The Netherlands and Finland, you see the stark difference. Since the 1960s the Finns have had a 7 pap test program, 5 yearly from 30 to 60 and they have the lowest rates of cc in the world and refer FAR fewer women for "treatments"/excess biopsies. The Dutch will shortly scrap their 7 pap test program and offer instead 5 HPV primary tests (or women can self-test) at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV+ and at risk will be offered a 5 yearly pap test. Most women are not even at risk and cannot benefit from pap testing. Adding HPV to population pap testing leads to the most over-investigation. Excess is profitable, but bad medicine.
Many of the problems highlighted by the article and the comments are related to the fact that healthcare in the US is market-driven. Patients demand more and more testing every day. Unnecessary and unproven testing is mistaken for thoroughness. A good place to start this would be to forbid any form of pharmaceutical, medical device and medical test advertising.
Price Transparency is an easy solution to this problem. If the patient knew what she had to pay up front for the Pap Smear she would opt for a cheaper test or see someone who would provide the screening at a lower cost. No need for a special committee to determine costs, or a special policy statement or any other bureaucratic nonsense. Price transparency would bring rapid and efficient cost savings.
Sounds as if a lot of people never think about their patients' bills. A $1000 EKG is eminently plausible, despite being outrageous. A patient of mine recently showed me her bill from a well-known hospital in Atlanta - the bill includes $23k for an EKG, $22.8k for an MRI, $16.4k for a CT, $31.8k OR charges for a vertebroplasty, and $19k for PT - which consisted (she says) of a single walk down the hall. (To add insult to injury, her discharge papers said she was being scheduled for lumbar diskectomy and fusion, which she was very distressed about, as her pain was entirely thoracic - luckily, that part of her discharge papers had another patient's name on it!)/ I almost always discuss cost with patients - whether of medications, tests, or procedures - if the sticker shock is too high, they won't fill the prescription of get the test done; if I tell them it should be cheap, or generic, they are much more motivated to follow my advise; if i tell them it is horribly expensive, but I still think it is important, then at least they have been "immunized" a little in advance . . . and I show them I am their advocate, not on the side of the big businesses that are overcharging them.
Unless former patients bring in EOBs or the doctor only does a few procedures or the doctor is on salary and someone else collects information, discussing co pay and deductible during a 15 minute office visit is logistical impossible. Each year someone adds "one more thing" to be funded by the decreasing fee paid for the 15 minute office visit. Hiring addition office help also comes out of that fee. So many articles are written as if the patient has no responsibilities. The patient buys insurance or is self insured. It is the patient's business arrangement with their insurance. I agree that academic hospital repeat and repeat tests without any regard to making a clinical decision based of the result. Each cost should lead to a decision before more cost is recommended. Doctors who x-ray every patient ever visit are wrong. I do choose the most cost effective treatment every time. In orthopedics the most expensive treatment may be the most cost effective. The most expensive portion of a patient's care are complications. Some are acts of God. There are basically two types: Ones where the results of treatment are delayed and Ones where the patient does get results they paid for.
I've been practicing for 30 years and believe we are spending a lot of money for little benefit. I've never understood virus-typing since the results aren't going to alter how I follow a patient. I think robotic surgery is largely marketing hype. I think the barrage of prenatal tests we're now expected to do routinely doesn't improve outcomes. Patients aren't happy when they get a $1500 bill for cystic fibrosis screening for no apparent reason. I once considered opening a cash-only gyn outpatient clinic for uninsured women. I imagined a clinic with prominently posted prices, much like Jiffy Lube. An annual exam would be $70; a minor complaint much cheaper. Automated lab machines ran about $1200. We found we could get Pap smears read for $30. I could stock a few meds like antibiotics for UTIs and dispense them for a small markup. The only problem was acquiring enough capital and paying for liability insurance in Illinois. However, as more and more young physicians find employment with health care systems whose goal is maximizing profit, the problem will only become worse.
I am an internal medicine resident at a community hospital. Sometimes, I see that close to 95% of tests we order return 'normal' as most of them were ordered unnecessarily. One of the biggest reasons for driving healthcare cost is the 'duplication of tests'. I see this issue every time. For example, if a patient had CT, MRI or expensive blood tests recently, the patient does not have the test results in hand. When he goes to another provider or hospital, physicians would like to know about the test results. I feel most of our (residents' and interns') time is spent in getting patients old records. Several times, we do not get the reports from outside provider/hospital or receive incomplete report. Sometimes it takes long time to get those records. This kind of situation always triggers repeating same tests regardless of costly or inexpensive ones. I have also seen when patients are transferred to a better hospital, for example, university hospitals, the physicians often repeat or add on the tests the patients had already undergone in a community hospital. The only solution is creating a nationwide collaboration of providers but unfortunately I do not see this happening in near future.
This is an excellent article alluding to some of the underlying factors that contribute to the ever increasing cost of health care. I applaud Dr. Bettigole for her conclusion, "it is becoming increasingly clear that physicians have an obligation to be good stewards of limited resources and to understand the financial effects that the orders we write have on our patients." However, there is a missing piece to the puzzle... and that is obtaining the actual cost from the facility in which they are performed. I have been conducing my PhD research specifically measuring cost knowledge among physicians (prescriber) and patient (consumer) in the ED. To determine each cohorts accuracy in estimated 'costs' I had to use CMS reimbursement fee schedule because cost information was considered 'proprietary' at the academic center where my research was conducted (as is the case with most hospitals). Until all stakeholders are willing to have systematic cost transparency for physicians and patients alike, it is unfair to shoulder physician with the full responsibility of educating patients especially if they are unable to obtain the information themselves.
Reading this article compels me to share an experience of less than 2 weeks ago when I visited older friends (married couple) to celebrate the wife's birthday. The husband showed me a small, yellowed document - the actual bill for his wife's 1932 birth. The bill has two line items: 7 days as an inpatient at $3/day ($21 total), and a delivery room charge of $12. The total bill was $33, but a discount of $5 was given since cash was paid before leaving the hospital. The final total cost for her birth was therefore $28. Using an inflation calculator, today's value of those $28 is $440. Although 7-day hospital stays are no longer allowed/needed for normal births, paying $440 in 2013 for a 7-day hospital stay AND delivery is as likely as being able to buy a new 2013 Ferrari F12 Berlinetta (more than $300K) for $6K. Working in the opposite direction, if the cost of groceries had increased in parallel with cost of healthcare, one would be paying $170 for one gallon of milk (US average $3.43). These examples certainly drive home the point that healthcare costs have risen alarmingly.
Patients ask me directly sometimes how much a procedure will cost, and quite frankly, I have no idea, even when it's my procedure. Health care reform should include price transparency, where the providers publish their actual price on the internet for every item or service. The insurances can reimburse what they will, but for the sanity of the system, there should be no secrets.
Have you thought about the legal liability side effects of trying to be financially cost effective and possibly not complying with standard of care practices?
This is not $1000 for a Pap smear...They are additional tests, being run in a specialty molecular lab with specialty equipment. Would you be ok with this additional testing if you had to submit separate samples for HPV, gonorrhea, chlamydia? If the patient's history and/or symptoms warrant examination for STD's are you going to refuse to order the test because the patient thinks that since there is one sample so she should only receive one charge? Educate your patients. Cervical screening is most effective when done once per year. We do not yet know the full effect of increasing the screening interval. When we extend the screening intervals to 3-5 years, more women are likely to show up with a cervical lesion that requires advanced, possibly traumatic treatment, not only to clear the lesion, but in the future when she wants to conceive/carry a child but cannot due to the cervical amputation sometimes used to treat dysplasia. A Pap per year is significantly less expensive than treatment of dysplasia and any type of fertility intervention. Sample collection is the first step in the success of the Pap. You have 1 chance per 3-5 years to get it right.
Dr. Bettigole, You are right it sounds like a lot, but it would be very helpful to know which tests were ordered, and why and where they were performed. HPV screening for high risk genotypes such as 16/18 is very effective for identifying young women at highest risk for cervical cancer who should undergo colposcopy. Other tests such as CT/NG or HSV may be warranted based on suspected high risk sexual activity, symptoms, or in cases of pregnancy, etc. Costs vary dramatically and are typically much higher within academic institutions than reference laboratories serving primary care outpatient clinics. Laboratories will often discount or subsidize charges extensively for patients in need when notified, but by law they must balance bill patients at least once to avoid Stark Law violations regarding suspected kickbacks or financial inducements to ordering physicians who refer tests to them. Rather than paint all laboratories with a broad brush of suspicion it would be very helpful to put this patient's clinical scenario into perspective with a sharper pencil detailing these contributing factors and explain why the patient was billed. Thank you. Best regards, Mike Dugan, M.D.
This is an excellent article and it is important to publish this in the professional literature. It follows recent newspaper publications (NY Times) describing reasons for the high medical costs (and comparatively bad outcomes) in the US as compared to other resource rich countries. There are obviously many factors involved; physicians and litigations play a role, next to the corporate worlds involved in healthcare and political lobbyism. It seems to me more and more less likely to fix the system without at least price control for diagnostic tests, medical devices, treatments, drugs etc - as is done in many European countries. Or better by giving more control to the patients as "consumers" of health care: forcing transparent pricing and thoughtful resource utilization. David Goldhill describes this nicely in "Catastrophic Care". Everybody who has worked in resource limited areas where patient and their families have to pay know it is possible.
As commented by several others above, this is typical of labs ways to jack up revenue. It's really easy to order a hepatitis panel, when we really just want limited testing. Same with allergy tests, many others.
In addition to the inappropriate cost associated with the ease and overmarkting of panel tests that in many cases are inconsistent with guideline recommendations or the patient's condition; the use of these panel tests are likely to result in more false positive test results, which will lead to innaproprite further testing, treatments or procedures. Some fraction of these patients will experience an adverse reaction or outcome. Thus, not only are patients financially paying too much for innapropriate testing as outlined by Dr. Bettigole but they are paying with worse outcomes.
Just the fact that there are such things as Laboratory Marketing Reps should be a huge red flag.There are many other ares where unnecessary testing is being promoted - sometimes overtly but often it's more subtle. A rapidly growing area of concern is genetic testing for screening purposes. For a given condition, Cystic Fibrosis, for example, there are a number of sites or markers that are worth testing for. However testing labs will market Genetic Panels to physicians which often contain dozens of tests that are of no significence for screening purposes. They do this because they can, technologically, and because they charge by the genetic marker site. This is often accomplished by providing phyicians with preprinted order forms (nothing new) on which the unnecessarily large panels are the most prominent. Commercial labs are making every effort to follow the sucessful lead of the pharmaceutical industry in profiting from our prescriptions for drugs and services that are not medically necessary.
Two points. The problem of pricing opacity is a general feature of medical care and is not limited to laboratory testing. As is well known in the medical economic literature, it is essentially impossible to obtain pricing data on any individual service, not least since that information is considered proprietary by the provider organizations and in some cases by law. An alternative approach to simply informing physicians of cost of any individual test/treatment (although that has been shown to reduce inappropriate usage) to provide a lump sum for medical treatment to the organization providing care and have that organization responsible for all aspects of that care, including on ancillary testing such as laboratory fees and radiology. The incentive that that would provide would be much more effective than an appeal to altruism over any individual item.
Unless there were fine prints on the information provided by the doctor's office, how can the doctors and labs justify those charges unless the patients agreed to have them performed without their implicit consent? When we take our cars to a repair shop, the mechanics have to wait for our consent/order before they can start fixing our cars and thinking about billing us. I have looked at thousands of Pap smear slides and saw quite a lot of them with evidence of gonorrhea - those cute coffee-bean-shaped, intracellular things, but I have never dreamed about starting a nice extra source of income.
To continue to allow insurers to underwrite their products is leading to this unconscionable burden. Why should anyone who is sick have to be told that the treatment has the potential of bankrupting you? This onus should be removed and the country must decide there is something dramatically different about purchasing health insurance. You may be healthy today and pick a plan that has a HD but tomorrow could be a different story. One way or another HD plans fly in the face of what health insurance is suppose to be about, namely removing the financial worry if one gets sick. The model of other types of insurance, such as car insurance, does not have one's very survival in the balance. There should be one basic insurance covering proper care, that is affordable and allows doctor and patient to decide freely what proper treatment is advised. If you go on the Mass Exchange there are close to 100 plans to choose from.....Ridiculous.
Recklessness and fraud in medical billing, if not restrained by effective management, is sending the country into bankruptcy. There are hundreds of examples like these, actively corrupting our ability as a nation to provide affordable health to our citizens. Were just 100 gifted federal employees furloughed from their present jobs to focus on such practices in federal contracting and reimbursement, there would be enough abuse exposed to fund the entire government for a good part of each year. The article should be required reading for legislative committees that are entrusted to write the rules for reimbursement by the government, and perhaps to set penalties for health institutions and their satellite labs; reimbursement penalties for continued corruptive practices. Paul Hoffman, retired founder of Oregon Research Institute.
Given the wide variation in hospital and pharmacy billing, coverage, and out-of-pocket co-pays, it is practically impossible to provide a patient with a reliable estimate of expected out-of-pocket costs for diagnosis or therapy. Why is it that our clinical healthcare information technology (CHIT) doesn't provide projections of the actual (insurer) and out-of-pocket (patient) costs? We use CHIT to order all these things and CHIT knows about insurers and payment plans and all the 'back office' stuff about drug and treatment costs. By now CHIT should not only be telling us the cost of the proposed DX and RX but also providing comparisons of alternatives. CHIT should be tracking each patient's yearly out-of-pocket totals and calculating when the yearly co-pay maximum will be reached. Indeed, if it is as transformative as its proponents claim, good CHIT would suggest when it is beneficial to push DX/RX forward into the current year and incur expense when the deductible has already been paid. The DX for Ubel et al.s problem is simple: bad CHIT.
An excellent article... should be made available to every doctor in the 3rd world, where an even more notorious and illegal practice of physician kick-backs is prevalent! As an example, for a physician in a non-practising hospital, the cost of a PET-CT scan is Rs. 8,000 to 12,000, while for a regular paying patient, it is nearly Rs. 32,000 - about 4 times more! This is because several 'specialist doctors' in India earn a living purely out of 'test prescribing', out of the kick-backs from the diagnostic services.
I applaud Dr. Bettigole for her sensible thoughts. When a resident in General Surgery 45 years ago, I made similar observations during Grand Rounds with The Professor in attendance. My suggestions were greeted by an embarrassed silence, followed by comments which said in effect that this was a great teaching center and we were not to be bothered with such trivial matters of cost. Indeed. Hugh Bartlett, M.D., FACS, retired.
? Symptomatic infections
Investigations and routine screening are valuable tools in detecting sexually transmitted infections, which are usually asymptomatic. From an European context, the costs quoted are exorbitant, and prohibitive. An effective and simpler tool to focus on those at risk is the simple question:- 'When did you last have sex?" This reveals those who are sexually active, and may need screening, whatever their age; and those who are not, and may be in even greater need of help.