Thursday, June 09, 2011
Well, I did not pay for it!
A gentleman in his mid 70's was in my office last week for his annual complete physical. He is a sage man, well respected in his profession. He had been found to have a mildly but significantly elevated PSA, prostate specific antigen. Appropriately, this abnormality was followed by an ultrasound and subsequent prostate biopsy. The results showed mild early prostate cancer.
The patient then went to Sloan Kettering in NYC for another opinion. Upon review of the biopsies, the conclusion was that it was NOT prostate cancer, but an early PRE-cancerous condition. None-the-less he was sent for an MRI of his pelvis and a whole body bone scan.
I expressed my concern for his problem, but I also expressed my surprise at the testing done at Sloan. It is hard to rationalize the MRI without evidence for aggressive prostate cancer. It is inexplicable to get the whole body bone scan in search of bony metastases in a case with no primary cancer.
I stated casually that I thought the tests were excessive and expensive.
He replied, "well, I did not have to pay for it!"
I emphatically corrected him, pointing out that he DID pay for it as a TAXPAYER.
And that is my main point: the third party payer system, in this case Medicare, has removed from the individual the mantle of personal responsibility for the cost of our medical care. Multiply the $5,000 (or more) in the cost of these unnecessary tests by the millions of Medicare recipients. The doctors ordered the tests without thought to the value, necessity, or cost.
The government's answer is controls and oversight and rationing: LESS personal responsibility.
My answer is the opposite: increased AUTONOMY of physicians and patients, and INCREASED responsibility.
Doctors must practice good scientific medicine. Diagnostic evaluations should be laser sharp and not shotgun splatter. Do the right tests in the right order, taking into account the impact of the tests on the decision process and the human and financial burden of the tests.
Patients must make informed choices and not just do whatever is recommended by the physicians.
The patient then went to Sloan Kettering in NYC for another opinion. Upon review of the biopsies, the conclusion was that it was NOT prostate cancer, but an early PRE-cancerous condition. None-the-less he was sent for an MRI of his pelvis and a whole body bone scan.
I expressed my concern for his problem, but I also expressed my surprise at the testing done at Sloan. It is hard to rationalize the MRI without evidence for aggressive prostate cancer. It is inexplicable to get the whole body bone scan in search of bony metastases in a case with no primary cancer.
I stated casually that I thought the tests were excessive and expensive.
He replied, "well, I did not have to pay for it!"
I emphatically corrected him, pointing out that he DID pay for it as a TAXPAYER.
And that is my main point: the third party payer system, in this case Medicare, has removed from the individual the mantle of personal responsibility for the cost of our medical care. Multiply the $5,000 (or more) in the cost of these unnecessary tests by the millions of Medicare recipients. The doctors ordered the tests without thought to the value, necessity, or cost.
The government's answer is controls and oversight and rationing: LESS personal responsibility.
My answer is the opposite: increased AUTONOMY of physicians and patients, and INCREASED responsibility.
Doctors must practice good scientific medicine. Diagnostic evaluations should be laser sharp and not shotgun splatter. Do the right tests in the right order, taking into account the impact of the tests on the decision process and the human and financial burden of the tests.
Patients must make informed choices and not just do whatever is recommended by the physicians.
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And we pay for such over-testing in additional ways, such as adding to our cumulative exposure to radiation...when the tests include x-rays or catscans! Tests are not always without risk, and often are without benefit to the patient's current circumstance. And the extra concern and stress induced from the tests and the waiting periods are not always innocuous either. I've seen lives temporally disrupted from irresponsible over-testing and it could set off a chain of medical events for someone with high-blood pressure or the like.
I agree with your philosophy, here!
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I agree with your philosophy, here!
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