Posted by: notdeaddinosaur | December 9, 2009

Another Idea to Limit Unnecessary Testing

Defensive medicine, defined as “additional and often unnecessary tests to avoid lawsuits”(1), is widely acknowledged as one of the biggest factors in spiraling health care costs. The problem is more than just testing specifically to defend against potential litigation. At issue is what to do when patients request/demand inappropriate testing. This has been driven home to me at least three times just in the last week.

From patients with no family history of anything and perfectly normal blood tests (cholesterol panels, blood sugars) a year ago who “really want it done again” despite the USPTF recommendation of 3-5 year intervals for these screenings, to women who demand annual paps “just to make sure everything’s okay in there,” I find myself struggling to explain the downside of unnecessary testing. “But the insurance will pay for it,” they respond. “What’s the harm?” Sometimes I do it; sometimes I stand my ground; but the encounters often leave me drained and upset. How much is my inability to explain these things adequately, and how much is it the deeply ingrained American idea of “more is better,” “better safe than sorry,” and so on? There seems to be no way to tell.

So how about trying out this idea to reduce expenses from unnecessary testing:

Third party insurances will only pay for tests not designated as “medically indicated” by a physician if they are abnormal.

Although one might propose requiring a physician’s version of a “certificate of necessity” (which we sort of already have; you can’t get a test without a physician’s order) whereby patients can get any test they want if they pay for it themselves, it looks really bad when that test comes back showing something unexpected. If insurance companies only pay for abnormal tests, patients have a little more skin in the game by taking on the risk of having to pay for negative tests. As most of them claim to only want the testing for “peace of mind,” it stands to reason that many of them would also be willing to pay.

This is philosophically similar to the concept of “loser pays” litigation, although a more familiar and less arbitrary-seeming example would be the NFL rule for charging coaches a time-out for challenging penalties that are subsequently upheld. However you look at it, increasing the potential risk — even only financial — to patients demanding unnecessary testing, while not penalizing them for the occasional accidental finding, is at the very least a novel idea for controlling health care costs that I believe deserves serious consideration.

(1) Baker, Ninja; Malpractice Tort Reform; 1 December, 2009; policy paper for HS104a American Health Care, Professor Altman; Brandeis University; page 3 (comment from TA HKI: “good definition.”)


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