July 28th, 2009

What’s an unnecessary medical test?

Amidst all the wrangling on health care reform, one of the issues that often comes up is the elimination of unnecessary medical tests. Although everyone would probably agree that such a savings in cost and trouble would be a consummation devoutly to be wished, the question is: “unnecessary” according to whom, and how would this be determined?

“Unnecessary” is usually defined ex post factor, after all, as in: “A medical test that my idiot doctor ordered, which cost me a lot of money and no small amount of time and trouble and even perhaps pain, and turned up nothing in the end.” But at the time the test is ordered, many (perhaps even most) patients think it’s best to leave no stone unturned, and are pleased that their doctor is being so thorough.

Although we may want cost-effectiveness to be the criteria on which the “necessity” of such tests is judged for others, we tend to want no stone left unturned when it’s own or our loved ones’ health at stake. Cost-effectiveness evaluations tend to be very cold-blooded: “X” number of dollars per life saved or per life-quality improved, and those lives are not always measured the same, with the value of a young person differing from that of an old one. These calculations trouble a great many Americans, and are among the reasons most of us prefer to be allowed to choose among a variety of private health insurance plans, some of them more and some of them less restrictive than others.

And what about the medical reasons for these “unnecessary” tests? A certain test may be not be especially cost-effective, in the sense that there might be only a small probability that that particular procedure will turn up something in any one individual. But it might still be judged medically necessary to run that test if a doctor wants to practice good medicine in a difficult-to-diagnose case, to make sure to rule out a treatable condition that could be dangerous if left undiagnosed. Assuming that the insurance covers the test and it is not exorbitantly costly, such decisions are usually based on a balancing of the risk of side effects or damage to the patient as a result of the test vs. the probability of its uncovering something treatable. That’s a different sort of cost/benefit evaluation.

And then there’s another definition of “necessity,” one we patients often ignore but one that is quite important to the doctor: the need of the medical professional to cover him/herself against lawsuits. This is one of the dirty secrets of medicine that Obamacare refuses to address. Some portion of “unnecessary” medical tests are an attempt by doctors to stave off lawsuits by showing they exercised all possible diligence in diagnosis.

I can only conclude that anyone pretending that the elimination of unnecessary tests would be easy, is being neither serious nor honest about health care reform. And I’ve seen absolutely no evidence that would even begin to convince me that the task is the proper province of government, or that government would do a good job in making such judgments.

30 Responses to “What’s an unnecessary medical test?”

  1. Artfldgr Says:

    its the test you take that you only find out you dont need afterwards…

  2. expat Says:

    A brain scan for Nancy Pellosi?

  3. Baklava Says:

    Computers are like people.

    OK they aren’t.

    But seriously. During my 20 year career, when a computer has a problem it’s URGENT. It needs to be fixed right away. And… I used to provide IT services for Kaiser in 1995 where doctor’s and nurses needed their computer up right away.

    OK. So where am I headed?

    During the process of troubleshooting and determining the root cause of a computer problem, you run tests, you run processes to isolate where teh problem lies, etc.

    And then as you get closer to discovering – btw there may be more than one problem and that is TRUE with the human body as well (yes I watch House he he) – you think to yourself, “gosh, if only I did this first

    Next time you learn – welp – that doesn’t always tell you….

    OK, That’s my contribution

  4. Baklava Says:

    Good thing I don’t need malpractice insurance to work on computers… sheesh..

  5. Richard Aubrey Says:

    What is interesting, has been mentioned before, but not much, is who decides which lifestyles are going to be targeted. Obesity? Smoking? Drinking? Promiscuous sex? If the government has to pay for the results of such things, each is a crime against the state.
    Parenthetically, if you’re in the military and, by neglect or some such, get yourself unfit for duty, it’s a violation of regs. Sunburn, for example. Redhead from MA goes on a two-day pass to Myrtle Beach on August. Happened in my company to a junior sergeant. He got some admin trouble.
    So which crimes against the state are going to be acceptable and which not?
    And how do we figure it out?

  6. rafinlay Says:

    “So which crimes against the state are going to be acceptable and which not?
    And how do we figure it out?”

    The usual way. Political lobbying, posturing, and pandering. What has been the cost/quality effectiveness of all the AIDS research? If that is the criterion, what disease could not be attacked? But for all the talk of some analytic approach, the decisions will be made poitically.

  7. rafinlay Says:

    Or perhaps “politically.”

  8. rafinlay Says:

    Although it might be interesting to see how it could be done “poetically.”

  9. Rose Says:

    Remember the movie, The Doctor? William Hurt? He was a doctor who thought he knew it all… until he became a patient

    There’s a scene where he admits to his newfound friend and fellow cancer patient, that her doctor could have ordered one test that might have saved her life, allowed diagnosis in time…

    These things matter. We are, or we were, a nation that was making enormous strides – where a few short Presidents ago all they could do, even for the President, who was having heart trouble was stick him in a tent, we can now save and extend life. We can save premature babies.

    It’s a strange disconnect that all these amazing and wonderful things have been done, are being done and we have this odd progressive mentality that ignores it all and paints this dead picture of doom and gloom and uses it as justification for draconian political agendas.

    My language is getting all twisted up trying to grok the thing.

    WHY? Why would my parents, who are the tail end of that Greatest Generation, willingly go along with the notion that we would not take ‘extraordinary’ measures to prolong their lives?

    Why have they bought into this Barack Obama fairy tale to the extent that they think he is so all knowing that he must be right about this?

    And why – If Obama is serious about the idea that old people should just lay down and die, and no “extraordinary” measures should be taken to save their lives – then – why doesn’t he – and the other Dems who support him, ask Ted Kennedy to forego all the “extraordinary” measures being taken to save and prolong his life? In fact, as a gesture of good faith, why doesn’t Kennedy voluntarily refuse all treatment from here on out?

    Because like all things Obama – the rhetoric doesn’t live well in the real world.

  10. Oh, bother Says:

    Obesity. The combatants are already jockeying for position.

    Or if you like, those funny black birds of paradise with the weird blue spots that Neo showed us a while ago are already jumping about trying to attract the attention of the professionally aggrieved, er, their potential mates.

  11. Artfldgr Says:

    first the unborn then the old and infirm will be next then the ones who the liberals believe cant have full lives. there was a term for it, i am loath to repeat it. as that goes on they will target more of the things we do that we enjoy (that are also bourgoisie). eventually there is nothing to have and nothing to do. then you learn to drink, but not too much, tomorrow there is still work. then… well wait and see why spoil the surprise?

  12. maneocon Says:

    Neo, the “X” you refer to has been addressed by NICE, the British board that sets what is cost effective treatment, as to be $22,000 to extend someone’s life by 6 months.

    I have a first person situation with this (and am sure other readers as well). For my condition, my regular doctor suggested surgery (which would work for 3 years and require another one again) – so, medium cost, second consult wanted to simply treat me with steroids to relieve the inflammation, although that would leave me in such immune suppressed state that the next sniffles would effectively kill me – cheapest, it only costs $4 for a month’s supply. And the last one chose what I believe is the right option, although an expensive one – at $5000 every 8 weeks. But in all this my private insurance left me and my doctor(s) to make the call. But under Obamacare and going with NICE standard, my treatment option is expensive. So, imagine the blue pill and the red pill theory, I guess I would get the steroids and would have long succumbed to one of many mini-Pneumonia episodes that I suffered to-date.
    I guess quality does not matter, just the quantity – in this case increasing the number of insured, though many may not be sick.

  13. Artfldgr Says:

    Senator Claire “ACORN” McCaskill held a town hall meeting in St. Louis on healthcare, i am glad this young man showed up

    http://www.youtube.com/watch?v=y98HxYbsdBM

  14. Occam's Beard Says:

    “What’s an unnecessary medical test?”

    One someone else gets.

    There’s an operational definition for ya.

  15. kcom Says:

    The other thing you can learn by watching “House” (even though in many respects its a wildly unrealistic show) is that no two patients are the same. They have all different ages, medical histories, travel histories, genetics, allergies, personalities, expectations, pain tolerances, support networks, etc., etc. There is no one-size-fits-all way to determine what a patient has or what tests he needs. That’s what the science and art of medicine is all about.

    Some stupid committee sitting in Washington can’t make the call about individual patients. All they can do is, in effect, say, “All else being equal, this treatment is better than that treatment for this condition.” But all else is never equal, because no two patient circumstances are the same. You need a doctor in there to use his judgment to make the call on what to do. And even in the same circumstances, two different doctors wouldn’t necessarily do the same thing. And then there are the cases where one treatment isn’t clearly better than another for a particular condition. The real world is messy and complicated.

    And lastly, my question would be, isn’t that properly the role of medical journals, and conferences, and continuing education anyway? All doctors already do that sort of studying now, as far as I am aware. I know my father did. He didn’t wait around for the government to tell him what treatments were effective and cost effective. He read journals and kept up. That’s a basic part of a doctor’s job and that’s what the medical profession is for. What they are proposing isn’t a medical necessity, it’s a political necessity.

  16. Wolla Dalbo Says:

    Today’s Washington Times has an April 28 New York times quote from Obama (http://tinyurl.com/nnk6ev) about “those toward the end of their lives [who] are accounting for potentially 80 percent of the total health care bill out here.”

    Given that this is Obama’s viewpoint, who do you think is going to predominantly get the axe to reduce health care costs in a national health care system? Three guesses and the first two don’t count; my guess is that it ain’t going to be the productive, tax-paying “spring chickens.”

    If you are all hot for euthanasia, dumping the oldest members of the tribe on a chunk of ice and turning your back to them as they disappear in the ice flow and the tribe moves on, then Obama’s the One or is it the Won for you; at least he is the Won for you until you yourself start to get old, and the mandatory, periodic “end of life counseling” starts.

  17. Nolanimrod Says:

    Neo,
    You described exactly what happened in a case I read about in The New Yorker.

    “A certain test may be not be especially cost-effective, in the sense that there might be only a small probability that that particular procedure will turn up something in any one individual. But it might still be judged medically necessary to run that test if a doctor wants to practice good medicine in a difficult-to-diagnose case, to make sure to rule out a treatable condition that could be dangerous if left undiagnosed.”

    This article was about a woman who had spent much of her youth and her entire adulthood to that point in mental hospitals. STATE mental hospitals.

    At some point a doctor looked in her eyes and noticed a greenish tinge. She wasn’t metabolizing copper proper properly. Wilson’s Disease. They treated that and she was fine.

    One small, “unnecessary test.”

  18. Mitch Miller Says:

    Ask Liam Nelson if an MRI for everyone who’s had a head injury, no matter how minor, is an unnecessary test.

  19. strcpy Says:

    Sadly, as I have said before it costs 10 dollars to treat person to our fullest extent – we have 10 people and 80 dollars to spend. Someone someplace has to have rationed health care.

    As far as unnecessary treatments lets say myself for example. About a year ago now I started have some cramps in my lower right abdomen. They slowly became … intense, and I mean really intense. Having little health insurance I reluctantly decided to go to the emergency room and on the walk down the steps the pain diminished and *mostly* went away in moments. I had already had ruled out appendix and noted kidney stones behave that way (including some strange pain symptoms). I obviously had blood in my urine, could feel the stone move, yet I never really knew I passed the stone once I felt it drop into my bladder.

    About three or four weeks later – same thing again. Scared this time (maybe it wasn’t a stone) I went to the doctor and they did a urinalysis and said yep – blood and chemicals consistent with a second stone. They sent me to an ultrasound person who said the same thing.

    Was that wasted? Well two stones within a month is not *that* unusual yet not that common. There isn’t much in that region to cause that amount of pain yet if it *had* been something else then emergency surgery and months or recuperation would have been needed. In hindsight it was “unneeded”, but had I been that .01% that would have died you better believe I would have said that was “needed”. There was no way to know unless the other test was done and, indeed, I bet there was still some question with *really* remote possibilities.

    In this case the tests were cheap, but had they not how would *you* make that decision? I couldn’t – again we can not afford to do them all and where do we draw that line? And then wherever you draw it some will be borderline and die yet really shouldn’t.

    In my case the decision was mine as to what I could afford given my current insurance. For some that rankles that someone else could choose to do more, for others that makes sense. However Obamacare doesn’t even make the understanding that this is the case let alone figure out where to draw the line. Even were it too I suspect that nothing short of “everything” would make the first group happy and that isn’t going to happen no matter how much we think we deserve it and declare it a basic right (I could also declare immorality a basic human right but it wouldn’t make me any less mortal).

  20. Richard Aubrey Says:

    Slightly different approach to the issue:
    My granddaughter is beautiful, brilliant, two years old, and so far perfectly healthy.
    Let’s think the unthinkable, which is that she becomes ill and the necessary medical treatment that is now available is no longer available under zerocare. She suffers, is permanently damaged, or dies.
    What is my relation to be with the people who voted dem and for zero?

  21. Rich Says:

    My sister works in a medical lab. Several years ago, she had to deal with a rather delicate situation. Someone had gotten their wires crossed, and run some tests on a patient which had not actually been ordered by the patient’s doctor. Normally, this would be merely a financial problem; in this case, however, one of the tests came back positive. My sister then had to explain to the doctor that his patient had a problem which (technically) no one could possibly know about, because it was revealed by an “unnecessary” test.

  22. Tom Says:

    As always, Neo gets it: Unnecessary is ex post facto in health care.

    The Democratic demagoguery, the gross distortions and the obscene lies, coupled with the fact that they can and will do these things to us all, has reduced me to a state of quiet desperation. The goodness of America is evaporating into the ether, being boiled off by these awful people to whom the benefit of doubt and trust was over-extended.

  23. Thomass Says:

    Spot on. The, say, 1 in 400 test is a great thing if your the 1.

    Anyway, it’s a ‘first they came for tests’ thing too. A lot of expensive treatments that even insurance pays now have kind of poor statistical results. I mean, my pacemaker cost over $100k after installation (and I don’t mean the bogus hospital bills that are not paid, I mean after the insurance discounts that much money changed hands)…. but statistically, 80% of people with heart failure still die within 5 years (even people under 60, but it goes to 7 years for 80% mortality). So… next, why spend $140k to extend life for a few years when only 20% live longer? After the anti ‘test’ mentality sticks in, how do you make these arguments?

    Mine argument is, it is none of your business. :) The fact that government healthcare will make people want to wonder about these things is why we need to keep government out.

  24. Thomass Says:

    Baklava Says:

    “OK, That’s my contribution”

    Its a good one. Doctors do similar things to isolate problems as computer techs… and your right, with people you have to do a diag flow chart which will mean eliminating possible causes… which will mean doing tests that come up negative before doing the next test…

    Same with computers… you start with dumb stuff just to eliminate it (is your power cord in… ok, is it plugged into the wall…)…

  25. Thomass Says:

    Baklava Says:

    “Good thing I don’t need malpractice insurance to work on computers… sheesh..”

    Heh, I had it. It was called ‘errors and omissions’ insurance. If anyone sued me and said my work caused them a loss (like I screwed up and erased their database or something)… I’d recommend having it.

  26. Maddog Says:

    Unnecessary medical tests are any test you would not agree to undergo and pay for if you had to pay out of pocket.

    The way to eliminate most but not all is to move people to major medical/high deductable ($3,000 – 5,000) policies.

    This is the only way we will ever control medical cost, since the real problem is overuse and second and third party payment based insurance.

    Maddog

  27. Wolla Dalbo Says:

    In the end this is not all about tests or medical procedures; it is all about who gets to choose, you or the government, it is about individual freedom and democracy or dictatorship, restriction and coercion, it is about taking money and choice from those who have worked to get them, and to redistribute that money to those who have not worked. You have your set of priorities–such as living a life that is meaningful to you as long as possible, or perhaps not prolonging a life that has become unbearable—your choice, the government will have it’s set of priorities—such as reducing health care costs, that really care nothing for you as a unique individual. In a democracy we should be able to put our money where our mouth is and make our own decisions, in a totalitarian state it is the state which decides how much money you are allowed to have, and what you are allowed to use it for; simple as that.

    It is more and more glaringly obvious with each passing day that Obama & Co. are for dictatorship, coercion and lies.

  28. Don Says:

    The Democrats are talking out of both sides of their mouth. On one hand, they are talking up the value of preventitive medicine, and on the other hand they are talking it down.

    After all, testing is a form of preventitive medicine. Find out about problems early so thety can be dealt with.

  29. Thomass Says:

    Maddog Says:

    “Unnecessary medical tests are any test you would not agree to undergo and pay for if you had to pay out of pocket.”

    I completely reject that. Until you have tests, and the resulting diagnosis via testing, you don’t know the consequences of not being diagnosed. You have to have the tests… to make rational decisions.

  30. frank Says:

    Well, it looks as though Obama and his Obamacare cronies are the ones that are going to decide who gets to live and who dies in the future…that is unless we stop Nationalized Healthcare…

    Obama will decide?

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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