Balancing Patient Demands and Physician Orders for Radiation Tests at the ER and Elsewhere

Photo by badjonni via Flickr

[Ed. Note: We are pleased to welcome Jennifer Jascoll to HRW. She is a second-year evening student at Seton Hall Law and a Research Assistant for the school’s Healthcare Compliance Certification Program.  She received her bachelor’s degree in Political Science from Bryn Mawr College and her master’s degree in Comparative Politics (Empire) from the London School of Economics and Political Science.]

Falling down stairs.  Hitting my head on a bowling ball.  Breaking my ankle and tearing two ligaments.  These are a few of the incidents that have landed me in the emergency room with a CT scan or an X-ray.  The AP has recently run four thought-provoking articles about the problems of balancing necessary and unnecessary tests administered during visits to the ER and elsewhere.

When should a person go to the ER? The American College of Emergency Physicians Foundation and other sources provide “tips” about the necessity of an ER visit when a person experiences symptoms such as:

• Difficulty breathing or shortness of breath
• Chest or upper abdominal pain or pressure lasting two minutes or more
• Loss of consciousness or sudden dizziness and weakness
• Confusion or changes in mental status

Fair enough.  The Foundation further advises patients to lower costs and “avoid unnecessary tests and procedures” by asking:

• Is this the best test or treatment?
• What are its costs, benefits, and risks?
• Are there alternative tests that are cheaper or less risky?
• Why do I need this test now, and what would happen if I don’t get it now?

Seems like common sense.  But just how many of us question the tests and procedures we undergo at the local ER?  Probably as many who think to ask whether our attending ER physician, in addition to the ER itself, is covered by our insurance.  After all, if a person is experiencing dizziness and confusion after hitting her head on a bowling ball, I doubt she will haggle over the necessity of a CT scan (or whether her attending physician is covered, which my father later tackled with the insurance company).

These tips may not get patients very far, however, as many ER physicians are said to overtest and overtreat for fear of malpractice lawsuits.  Lindsey Tanner, an AP reporter, writes that:

[t]he fear of missing something weighs heavily on every doctor’s mind.  But the stakes are highest in the ER, and that fear often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches.

Maybe there shouldn’t be too much surprise here.  According to Dr. Angela Gardner, president of the American College of Emergency Physicians, ER physicians are among the 10 specialists most likely to be sued:

Our society puts more weight on technology than on physical exams….  In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell you something for sure?

Increased patient demand for imaging tests coupled with a concern that not placating that demand will create unhappy and litigious patients would also seem to play a role.

Overtesting doesn’t just apply to ER visits.  AP medical writer Marilynn Marchione reports a trend in this country favoring imaging tests over physical examinations, in particular the CT scan which requires radiation (as opposed to the ultrasound or the MRI which does not).  You can receive 10-20 millisieverts (measurement for radiation dose) from a single chest or abdominal CT scan.  Compare that number to the 2 millisieverts you receive from exposure to the sun and soil every year.  Have one or two CT scans in a year and you’re looking at 20-40 millisieverts or 10-20 times your annual exposure to natural background radiation.  (For a list of other comparisons, click here.)

Our citizens receive more medical radiation than those in any other country and no one — neither physicians nor patients — really seems to be keeping track of the dose accumulation.  At least for the moment.  Marchione writes that:

[d]octors don’t keep track of radiation given their patients — they order a test, not a dose.  Except for mammograms, there are no federal rules on radiation dose. Children and young women, who are most vulnerable to radiation harm, sometimes get too much at busy imaging centers that don’t adjust doses for each patient’s size.

That may soon change….  FDA officials [have] described steps in the works, including possibly requiring device makers to print the radiation dose on each X-ray or other image so patients and doctors can see how much was given.

The FDA also is pushing industry and doctors to set standard doses for common tests such as CT scans.

There are efforts to educate patients on the risk of side effects from unnecessary radiation exposure in order to curb demand.  AP medical writer Lauran Neergaard reports on a Minnesota health cooperative which displays national radiology guidelines in a patient’s electronic medical records whenever a physician orders a scan.  The guidelines help physicians deal with patient pressure and determine whether a radiation scan is necessary.  The cooperative estimates it prevented 20,000 unnecessary tests and saved $14 million through this process.  Archives of Internal Medicine, an American Medical Association journal, also started a “Less is More” feature which, according to editor Dr. Rita F. Redberg, offers articles “that document cases in which less health care results in better health and offer[s] commentary on the specific implications.”

Patients are advised to question the necessity of a radiation scan and physicians are advised to reconsider ordering one, but just how many will do so and what will it really take to get people to listen on a national scale?

Physician Shortage in Relation to Compensation

The New York Times has run an article regarding physician shortages and physician compensation that is well worth a read. The Times reports that Obama administration officials

said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans.

One proposal - to increase Medicare payments to general practitioners, at the expense of high-paid specialists - has touched off a lobbying fight.

But as the Times article does not give particulars as to physician compensation, it may be of some help to actually look at the numbers.  To do so, I’ve re-posted this blog from a few months back. If, after you’ve looked at the numbers, you would like some explanation as to why they are the way they are, Professor Frank Pasquale’s post, Will Specialist Pay Be a Target of Health Care Reform?, will also serve you well. For an even further look at physician compensation, click here, and for a look at physician shortage matters click here.

Physician Compensation II

Yesterday’s post displayed recent Bureau of Labor Statistic figures concerning physician compensation, and offered a link to recent median physician compensation data approved for use by Centers for Medicare and Medicaid Services (CMS) for calculations regarding direct graduate medical education under 42 CFR 413.78(f). The producer of this data, AMGA, also offers an interactive physician compensation survey which shows “average” and “starting” compensation for various specialties. A click on the arrow underneath “average” will sort from lowest to highest.

Here below is a list of a few of the CMS approved median physician compensation figures for a number of different specialties. The numbers are taken from the 2008 report.

The median compensation for a practitioner:

• Pediatric & Adolescent, Internal 161,444
• Pediatric & Adolescent, Infect. Disease 174,154
• Family Medicine, w/out Obstetrics 176,280
• Family Med., w/out Obst., Branch* 190,182
• Geriatrics 179,344
• Podiatry: 180,080
• Transplant Surgery, Kidney 368,750
• Dermatology, Branch* 301,111
• Dermatology, Mohs 423,848
• Not neural, Non-Interventionist, Radiology 420,858
• Mammography 540,028
• Orthopedic Surgery, Spine 611,670

*Branch is defined by AMGA as: These specialties have the same basic definition as the main specialty. These physicians located in small satellite or branch offices at least five miles from the main campus. The branch office practices primarily as its own separate entity, and often has different compensation and/or performance expectations than its main campus colleagues, there would be no teaching responsibilities at these locations.

With these numbers, over the course of ten career years, if calculated at a constant rate without regard to future increases in compensation, the median paid “Family Doctor, Branch” will have earned $1,900,182. During those same static ten years, a “Mammographer” will have earned $5,400,280. If the Family Doctor were to consult with the Mammographer at the end of those ten years, she would be doing so with someone who had made $3,500,098 more than she-nearly 3 times as much. If that same Family Doctor were to then consult with someone from the lowest paid of the three categories of Radiologist, Not neural, Non-Interventionist, she would be doing so with someone who had made $4,208,580 during that time-which would be $2,308,398 more than she-or more than twice as much.

Perhaps by way of consolation for the PCP, the Geriatrics specialist and the Pediatric Infectious Disease specialist would have fared worse, and even the Kidney transplant specialist who consults with the radiologist would be speaking with someone who had made a half of a million dollars more than he did.

But perhaps it is not consolation enough; the AMA has reported that the nation faces a shortage of 35,000 to 40,000 Primary Care Physicians.

Medical Imaging: Why Are We Spending So Much?

Photo by Raziel via Wikimedia Commons

The NY Times article “Good or Useless, Medical Scans Cost the Same” states that the use of outdated medical imaging machines and the growing number of unnecessary scans performed each year are contributing to excessive medical imaging costs.  The article reports that the cost of medical imaging has reached $100 billion a year in the United States, with over 95 million high-tech scans being performed annually.  However, an astounding number of these scans have been shown to be either unnecessary or useless; the result is a waste of resources, patients’ time, and money, and the creation of untold needless worry.   According to a recent study by America’s Health Insurance Plans, the number of medical imaging tests increased by 40 percent from 2000-2005 and it is estimated that one third of these tests are inappropriate, costing the country between $3-7 billion a year.

It is not only the sheer number of medical imaging tests (necessary and unnecessary), such as MRIs, CT scans, and PET scans, that is contributing to the overall cost of medical imaging.  Other factors adding to the fact that insurers’ expenditures on medical imaging are growing at 18-20% annually are the use of older imaging machines, the growing trend of physicians who have ownership interests in imaging machines, and radiologists’ high compensation.

Currently, imaging centers are not required to, but may choose to, become accredited by The American College of Radiology.   Therefore, the age of an imaging machine is not regulated and older machines may produce blurry or poor scans.  This leads to repeat tests and misdiagnoses, which can result in an illness remaining undetected or even unnecessary surgery, as is depicted in the NY Times article.

In the current system, compensation is not based on the quality of the scan and therefore there is no incentive for the facility or physician to purchase a new and very costly imaging machine.  As the Wall St. Journal Health Blog points out radiologists read the scans and the insurer who pays for the scan never sees it to determine its quality. Read more

A Shortage of General Surgeons, Rural Hospitals Must Compete

The Washington Post ran a story today, “Shortage of General Surgeons Endangers Rural Americans,” which, as the title suggests, reported on the shortage of general surgeons. The story describes the sort “jack of all (surgical) trades” existence of a general surgeon and reports that “In 1980, 945 newly trained general surgeons were certified in the United States. In 2008, the number was essentially the same — 972 — even though the population has increased by 79 million. In 1994, there were 7.1 general surgeons per 100,000 people. Today there are five per 100,000.”

WaPo reports

“For the one-quarter of Americans who live outside metropolitan areas, general surgeons are the essential ingredient that keeps full-service medical care within reach. Without general surgeons as backup, family practitioners can’t deliver babies, emergency rooms can’t take trauma cases, and most internists won’t do complicated procedures such as colonoscopies. But various forces — educational, medical and sociological — are making them an endangered species.”

“Many young physicians are opting for non-surgical specialties, such as radiology or cardiology, in which they can earn as much money as a surgeon with less grueling and unpredictable hours. Many young surgeons, in turn, choose to concentrate in fields such as transplant surgery or plastic surgery, in which they can make more money and don’t have to face (usually alone) the wide range of problems a generalist faces.”

Importantly, the article discusses efforts to recruit new general surgeons and relative compensation incentives; it recounts how 57 year old Bob Kuhl, who has spent his entire career as a general surgeon in Creston Iowa, threatened to quit 18 months ago because “When the hospital hired Kuhl’s younger partner, it guaranteed him a salary greater than the $185,000 the older man had been making.” The hospital, however, is said to have made arrangements to assure Kuhl “a higher income, too.”

It is perhaps important to note that the recruitment of general surgeons is said to compete with such lucrative non-surgical specialties such as radiology. As posted recently, the median compensation for a not neural, non-interventionist radiologist is $420,858. As noted in another recent post, this level of radiologist compensation has been ably attributed on Ezra Klein’s blog to advances in technology and antiquated fee for service structures:

“Now because of the explosion of imaging, and practice efficiency, these guys are reading 3x the images they did 15 years, and making three times as much.”

The post on Mr. Klein’s blog assures us that “Eventually, payors and Medicare figures things out and start putting pressures on rates. But it takes a while.” Unfortunately, it seems that as hospitals and other medical providers must compete against such “not yet figured out” largesse for the services of newly minted physicians, the damage has been done– and a benchmark has been set.