The uncomfortable spotlight of overtesting

Anyone who's had a health scare, no matter how benign, knows the visceral feeling of confusion, anxiety and, in most cases, abject cluelessness.

It's that cluelessness that's particularly nagging: A feeling that you've suddenly lost control of your own body. The doctor recommends a battery of tests and you nod your head vigorously. Give me all the tests, you think.

It's a chain of events that's commonplace in healthcare, and it's led to a philosophy of unrestrained overtreatment in which both physicians and patients own varying degrees of blame.

Atul Gawande, M.D. author of The Checklist Manifesto: How to Get Things Right, and most recently, Being Mortal: Medicine and What Matters in the End, offered an in-depth exploration of overtreatment in the most recent issue of the New Yorker. If you have 30 to 45 minutes to spare, it's well worth your time, if only to get a feel for how complicated this problem is and how, collectively, we could dig ourselves out of the hole.

It's not the first time Gawande has broached this topic. A 2009 New Yorker piece focused on the town of McAllen, Texas. The town had the dubious honor of offering the most expensive healthcare in the country, with Medicare paying $15,000 per enrollee in 2006. In the nearby town of El Paso, with similar demographics, Medicare paid half as much.

Looking back, it seems McAllen merely set the trend. (It's worth noting that in the years after the Guwande's 2009 article, a slew of fraud settlements and prosecutions streamed through, including a $28 million settlement paid by seven physicians for taking illegal kickbacks).

Over the last several years, physicians and health experts have become acutely aware of the financial and safety costs associated with overtesting.

  • A recent New England Journal of Medicine study showed that unnecessary preoperative tests are driving up the cost of cataract surgery.
  • In a 2013 study evaluating laboratory testing, researchers found that 30 percent of all lab tests are probably unnecessary.
  • Last year, the AARP identified 10 overused tests that provide few positive benefits, including electrocardiograms and imaging tests for back pain.
  • Prior to that, the American Association of Critical-Care Nurses (AACN) released five routine care practices that are unnecessary or harmful, and the "Choosing Wisely" campaign has routinely identifies areas in which overtesting is problematic.
  • Perhaps most telling, a 2011 study estimated that 12 types of unnecessary tests cost $6.8 billion each year.

It's easy to blame physicians for this problem. After all, they order these tests. But, as Gawande pointed out, the reality is not that simple. For physicians, overtesting is a mark of diligence.

"As a doctor, I am far more concerned about doing too little than doing too much. It's the scan, the test, the operation that I should have done that sticks with me--sometimes for years," he writes.

We've reached a point where medical philosophy dictates that if a test or a procedure can be done, we might as well do it, and patients have obediently fallen in line. Gawande recounts the story of one patient who opted to remove her thyroid because of a 5-millimeter nodule that had a statistically insignificant chance of developing into cancer. In the end, she opted for the risky surgery to assuage her fears.

There are impossibly tough hurdles to reducing medically unnecessary tests and procedures, both for doctors and patients. There are signs that a transition is underway--one driven by insurers such as WellCare, which sees the benefits of creating a payment structure in which primary care physicians are encouraged to spend more time with patients and avoid costly and unnecessary referrals, which often lead to more unnecessary testing.

The majority of physicians who order unnecessary tests do not intentionally game the system, but the system is structured in a way in which overtesting is financially beneficial. Now it's seeped into our collective psyche, offering peace of mind for both the physician and the patient.

The backlash to Gawande's 2009 article offered a peek into how contentious this issue really is. A physician quoted in the article was virtually blacklisted and nearly forced to retire. Guwande was reviled for exposing the town to the rest of the country. Since then, however, spending has declined significantly. The spotlight, no matter how harsh, illuminated an obvious flaw. Once the initial anger subsided, providers had a new perspective.

It's clear that overtesting is a problem, but it's a problem so steadfastly ingrained in our healthcare culture that it will be hard to sift out. Physicians fear the government's overreach--a bureaucrat in a nice suit second-guessing their medical expertise--and patients, so often drowning in an unfamiliar sea of medical jargon, fear the consequences of doing too little.

Six years later, McAllen is a microcosm of the country. Measurable change won't take place until both physicians and patients are able to comfortably bask in the spotlight. - Evan (@HealthPayer)