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.