Curbing unnecessary testing

Dr. Lucy Hornstein, a family practice physician who blogs at Musings of a Dinosaur (and has recently published a book), made an intriguing suggestion this week: If a patient asks for a test the physician deems is medically unnecessary and the test results show nothing out of the ordinary, the patient should pay for it. But if there’s an abnormal result, insurance should pay.

There’s no denying that tests are contributing a significant chunk to the overall cost of medical care in the United States. Some of it, as Dr. Hornstein points out, is defensive medicine on the part of physicians. But there’s more to it than this, she writes:

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 USPSTF recommendation of 3-5 year intervals for these screenings, to women who demand annual paps “just to make sure everything’s OK 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.

She reasons that if insurance companies only pay for medically unnecessary testing when the results are abnormal, “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.”

It’s true that health insurance tends to insulate most of us from the actual cost of health care. This is becoming less the case as more and more people switch to higher deductibles or health savings accounts, which has increased their out-of-pocket expenses. The idea is that when consumers have to pay for some of their care themselves, they’re more likely to think twice before seeking care that might be unnecessary.

I’m not sure if this same dynamic would play out for medically inappropriate screening, especially when the determination whether to cover it wouldn’t be made until after the fact. Nor is it clear how much money would actually be saved. Regardless of who pays the bill, there’s still a cost to the provider for staffing, supplies, use of equipment and so on. 

What’s unnecessary, of course, might be in the eye of the beholder. What price tag do you put on peace of mind? People don’t always go to the doctor because they want to know what’s wrong with them; oftentimes they go because they want reassurance that something isn’t wrong with them. And as we’ve seen in the case of the U.S. Preventive Services Task Force and its recent new recommendation on mammograms, it can be very hard to sell the public on the concept that testing isn’t always what it’s cracked up to be. 

In any case, Dr. Hornstein has made an interesting proposal, and I’m curious to know what readers think.

Update: When it comes to patient requests for additional testing, are doctors darned if they do and darned if they don’t? Here’s another look at this issue.

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