Sunday, May 29, 2011

Money?

I thought it was timely that this article came out in the Star.



Many complain of having to pay for unnecessary tests

PETALING JAYA: A retiree seeking treatment at a private hospital was asked to undergo a blood test, X-ray and an ultrasound therapy. He was referred to three specialists an orthopaedic surgeon, a physician and a nephrologist and was admitted for three days. He had gone to the doctor for his gout.
The retiree, who has no medical insurance, claimed he was
eventually discharged with some painkillers and slapped with a RM2,700 bill.



Timely, as I recently became somewhat disillusioned by an incident involving a private hospital. Someone I know recently underwent evaluation for exertional chest discomfort in a private hospital. Now, I can't claim to be a cardiologist as my subspecialty lies in another area, though I am board-certified in internal medicine, and do try to stay up to date with the current guidelines. And I was surprised, that without even recommending something like a stress test, the cardiologist provided two options: a coronary CT scan, or an angiogram. In addition, he ordered a panel of blood tests including VDRL, hepatitis screen, CEA and alpha-fetoprotein.



Now, this confuses me. While many would agree the cardiac CT shows uch promise as a screening tool, all it would show is presence of coronary calcium and plaque; it gives little information (unless the amount of narrowing is unequivocally significant) on whether the calcium you're seeing on the scan is indeed causing ischemia and hence the symptoms. And an angiogram, on the other hand, was like pulling out the big gun, which is invasive and itself may cause an MI and death in rare causes, to work up a hunch.



Perhaps I'm not qualified to comment. Perhaps it's because I'm not a cardiologist, much less a practitioner in Malaysia where systems differ, but here, the first thing one ought to do is to test the hypothesis that the symptoms are indeed angina, from a lack of oxygen to the heart muscle that is accentuated by exercise. Depending on level of suspicion, and patient variables, this may be as simple as an exercise EKG, stress echocardiogram, or one of the many nuclear stress tests. And if things are suspicious, perhaps the angiogram would then be offered. The CT itself is more of a screen (arguably for the rich) and doesn't tell you much unless it's totally clean. In other words, the test has a pretty good negative predictive value. However this would be rare in the older population where you're bound to find coronary calcium in quite a number of patients and you don't really know if this is the cause of the symptoms. Some studies have found a positive predictive value of only 38% with the MSCT coronary angiography with the 64-row CT scanner.



Thankfully, in this case, the CT was negative and so we could lay the matter to rest. Despite that, I could not understand why this cardiologist recommended Clopidogrel, and switched his statin medication from a cheap generic to a nongeneric brand when his LDL ('bad cholesterol') was 69 mg/dL, with his HDL ('good' cholesterol') being even higher at 73 mg/dL. In my patients, arguably many would be happy with an LDL of 130 mg/dL, or less than 100 mg/dL if you have diabetes, or even if you had vascular disease, less than70 mg/dL.



So, maybe it's an assumption on my part, but the only conclusion that I can come up with, is that this was purely financially driven. And no, I'm not accusing all physicians of all private hospitals of being greedy, but for some of them, you do wonder.



As doctors, yes I admit we have to make some money. We have families to feed, mortgage, loans and maybe even some to spend on 'toys'. Like any occupation, making money is a necessity though in doctors' cases the patient-doctor relationship and sacred trust is a bonus. It's a priviledge that another human being lets you look (somethings literally!) into them, and to share every intimate part of their health with you. You look to the doctor and you trust that he has your best health interest in mind. It's a leap of faith.
But when you get the sense that the doctor sitting across the table is suggesting certain testing based primarily on financial motives, then it really leaves a bad taste in the mouth.

13 Comments:

Anonymous Anonymous said...

In the UK, exercise ECG is now not recommended as a diagnostic tool for patients with no previous documented CAD. In low risk patients, CT calcium scoring is used as 1st line investigation.

5:46 PM  
Blogger vagus said...

Calcium CT in low risk pts?? Why?
Why choose a test with a lower specificity and hence false positive rates, unless one wishes to falsely catch something borderline only to recommend the RM20,000 angiogram later?
Help me understand the research evidence behind this. Is this based on any consensus guidelines or expert opinion?
With NHS stretched so thin (so I hear) I'm surprised this is the practice in the UK.
Also, I'd argue that a cardiologist working someone up for chest pains, has no business ordering labs like alpha-fetoprotein, VDRL (come on, looking for syphilis???), CEA and rheumatoid factor.

7:37 PM  
Blogger Palmdoc said...

Regarding the issue of "financial motive", see this link:
http://thestar.com.my/news/story.asp?file=/2011/5/29/nation/8782482&sec=nation

"Association of Private Hospitals of Malaysia president Datuk Dr Jacob Thomas points out that doctors are not paid for medical tests that they order for a patient as almost all private hospitals in Malaysia are owned by corporations and not doctors.
“The medical specialists who work in one or more of these facilities are not owners and have an independent contractor' status,” he adds.
“These specialists are credentialed to practise in one or more of these facilities . They do not own the hospital or its equipment. They, in fact, pay a rental for the clinic sessions which they choose to maintain.”

9:40 PM  
Anonymous mayan said...

as a medical practitioner in msia, i see this ALL THE TIME... patients get "referred" to govt hospitals from private hospitals as "the patient prefers treatment at your hospital due to financial constraints"... when we take a full history, we discover that patients are charged for various tests that are actually unnecessary for their symptoms.. so they drain the patient's pockets, then send them packing to the govt hospitals when their funds run out... even if patients are really sick & on death's door, they make sure that the patient settles the bill first, then sends them packing to us... only to die within minutes of arriving through our doors

5:53 AM  
Anonymous Anonymous said...

http://www.nice.org.uk/nicemedia/live/12947/47931/47931.pdf

5:54 AM  
Blogger vagus said...

Thanks for the numerous comments; this is certainly an interesting debate. Thanks for the PDF link. I'm fascinated reading it; the same articles comments:
"Further disadvantages of 64-slice CT coronary angiography include; poor correlation with coronary angiography in calcified vessels as extensive calcification obscures imaging of coronary arteries, poor correlation with
coronary angiography for quantifying stenosis severity when > 50% and in vessels < 2 mm, no functional assessment of myocardial ischaemia, the potential for motion artifacts due to beating of the heart, and the fact that scanners may not be readily available. While the very recent publications on the diagnostic accuracy of 64-slice CT
have reported excellent sensitivity, specificity, PPV and NPV compared with other non-invasive test it should be noted that there is a possibility of
publication bias. The evaluation of new technologies is often performed inbias. The evaluation of new technologies is often performed in highly selected populations that have been referred for coronary angiography.
The evaluation of 64-slice CT coronary angiography has been performed on patients who have high pre-test likelihoods of CAD (high median prevalence of CAD). However in everyday clinical practice, 64-slice CT coronary
angiography is likely to be performed in patients where there is a low to intermediate probability, and the diagnostic performance of the test requires
evaluation in unselected populations."

So it's interesting that Chart 2 suggests the use of CT in low-risk populations. The more recent studies they cite gives a surprisingly high specificity that goes against many others- one wonders if this is related to what the guidelines authors themselves are hinting at- a selection bias of high-probability cases. I respectfully and humbly disagree with the guidelines- good thing I'm an endocrinologist, huh? :)

Indeed, a recent study in low risk patients (albeit asymptomatic) published in Archives of Int Med suggests against the use of CT in low risk populations.

http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.204

Palmdoc- I'm curious. Is there pressure from the hospital then, to generate income, from radiological tests or labs? Do doctors make a 'production bonus' if the hospital makes a certain amount of money? Even if we're not talking about the CT issue, I can only assume there is some motive to either the doctor or the hospital itself based on the numerous unnecessary lab tests that were done in this case. Because medically I cannot justify those labs.

I complain about the insurance companies here all the time; but one good thing about them is as doctors we have to justify why certain tests are done for a problem the pt has come to see us for, otherwise the patients' insurance won't pay for it. So explaining a hepatitis panel and syphilis screen when pts come for exertional discomfort would require a very imaginative mind! :)

7:35 AM  
Anonymous If it ain't symptomatic don't fix it said...

Asymptomatic screening is always a bad idea

4:56 PM  
Anonymous Anonymous said...

I had stress ECG done after consulting cardiologist about chest discomfort & headaches during morning exercise. Right after the test, the nurse whispered, Do you have a family history of heart disease ? AAARGH. I had Mild Hypertension with 2 unrelated major surgery within a span of 2mths. Cardiologist gave me two option 1.Angiogram 2.CT Angiogram, both same cost RM3800, except the CT is to be done at Heart Scan ctr.

I made the mistake of making a hurried decision, ie not seeking 2nd opinion thus opted for non invasive which I found out later to my dismay exposed me to unnecessary radiation risk. The CT scan (64MSCT) result normal, my heart turns out to be good for another 10yrs. Turns out my stress ECG test is False Positive.

The heart scan centre is damn impressive with photographs of well known people who has been there, done that..scan - I don't know. What I do know now is that I regret making a hurried decision & the cardiologist remarked "I asked for it!!" Sometimes I feel like wringing his ears & slapping myself.

6:56 AM  
Blogger Sai said...

Hello,

Do people not opt for a second opinion second opinion because it is difficult to get?
It's better to be safe than be sorry, isn't it?

Thanks,
Sai
http://blog.pinkwhalehealthcare.com

11:06 AM  
Blogger huajern said...

A rebuttal from a private cardiologist in Malaysia.
http://hmatter.blogspot.com/2011/05/replying-to-star-testing-patient.html

11:58 AM  
Blogger vagus said...

Actually I agree with the essence of Dr. Ng's commentary and I'm a big fan of his blog's. I agree accountability is important. Whether it's personal accountability, or the hospital's. With all the added tests, someone HAS to be making money and perhaps I was misguided thinking it is the physician, when the actual profiteer may be the hospital as a whole. But I am 101% sure that the added tests of cancer markers, inflammatory markers, immunological tests and STD testing done out of context has to profit someone. If not the physician, then the lab, or the hospital (though perhaps someone can enlighten, if the cardiologist orders the angiogram and then does the procedure himself, does he not get paid for that? I'd be surprised if he isn't).
Even if the physician was not ordering tests and labs for profit, it WILL COST the patient more money. And if one is ordering medically unnecessary tests for any other reason than financial motives(out of ignorance of evidence-based medicine, or lack of clinical judgment, or just little regard for financial burden to the patient?), does not make it right either.

5:31 PM  
Anonymous fibrate said...

There is no role for CTA as a screening tool. However the person mentioned had exertional chest discomfort, and depending on his other risk features that would determine his coronary artery disease probability, CTA as a primary assessment tool (instead of stress ECG or ECHO) is not entirely unjustified. Of course, the patient must be made aware of other options so that he can make an informed decision. No one test is perfect, some provide functional information, others anatomical.

Of course, I'm with you on the financially-driven practices of some of our colleagues. Needlessly screening asymptomatic patients (especially if they have "insurance") is a waste of resources and may even cause harm to the patients. Having said that you can't deny that there is an interesting demographic group called the Worried Well who will continuously seek screening tests - I know one asymptomatic patient who gets "surveillance" coronary angiogram ANNUALLY. Maybe he thinks the contrast agent will keep his arteries clean!

12:07 PM  
Anonymous Anonymous said...

I have seen this happen here in the US even, a man comes in with a one day febrile history gets CT'ed from head to toe, a whole bunch of lab tests only to be told it's likely a viral illness, it happens everywhere there is privatized medicine, it will always be the case, whenever you associate medicine with money that's what you get!

4:39 AM  

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