Costly, Repeat Medical Testing Common for Medicare Patients: Study
Whether these follow-up procedures are needed is up for debate, experts say
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Monday, November 19, 2012
"There is a substantial amount of retesting," said study co-author Kevin Hayes, a policy analyst at the Medicare Payment Advisory Commission in Washington, D.C. "There are also limited practice guidelines to help physicians understand when it's a good idea to repeat a test and when it's not."
That depends, said an expert who's familiar with the study findings.
"There is retesting for good reasons and there is retesting for bad reasons," said Dr. Nick Fitterman, director of the hospitalist program and chief of staff at Huntington Hospital, in Huntington, N.Y. Good reasons for retesting include when test results are botched, tests to check the effectiveness of a treatment and to monitor an ongoing condition, he suggested.
But other factors that lead to possibly unneeded testing are patient demand and fear of being sued for malpractice, he said.
The new report was published in the Nov. 19 online edition of the Archives of Internal Medicine.
Researchers looked at testing in a random sample of 5 percent of Medicare patients from January 2004 through December 2006. They focused on the tests most often repeated in the 50 largest U.S. cities.
For six common tests, one-third to one-half were repeated during the three-year period. "This finding raises the question whether some physicians are routinely repeating diagnostic tests," the study authors wrote.
Fifty-five percent of patients who underwent a heart test called an echocardiogram had a second such test. In addition, 44 percent of those who had an imaging stress test had another within three years.
The pattern continued for 49 percent of those who had a lung function test and 46 percent of those who had a chest CT scan. Forty-one percent of those who had a bladder test called a cystoscopy and 35 percent of patients who had an endoscopy of their digestive tracts had these exams more than once.
Testing varied by geography. For example, patients in Miami tended to have more echocardiograms, while patients in Portland, Ore., had the fewest.
"Diagnostic tests are frequently repeated among Medicare beneficiaries. This has important implications not only for the capacity to serve new patients and the ability to contain costs but also for the health of the population," the study authors concluded.
The authors noted that while the tests themselves pose little immediate risk, "repeat testing is a major risk factor for incidental detection and overdiagnosis."
In an accompanying journal editorial, Dr. Jerome Kassirer at Tufts University and Dr. Arnold Milstein at Stanford University wrote that "it is discouraging to contemplate fresh evidence . . . of our failure to curb waste of health care resources."
The editorialists recommend new and better physician guidelines and the end of payment incentives tied to services performed -- such as tests.
Fitterman agreed. "The 800-pound gorilla in the room is that we live in a fee-for-services world; there are financial incentives to do repeat testing," he said.
Part of the answer is to move away from fee-for-service and replace it with practice-redesign using evidence-based guidelines, Fitterman added. And he suggested limiting malpractice liability when doctors follow these guidelines.
Kassirer and Milstein concluded: "No matter what future payment system is implemented, some intercession in clinical decision making will be required to protect patients from too many tests and from too few tests. We have not come close to getting it right."
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