The Cost Of Diagnosis
The threshold for diagnosis has fallen too low. Physicians are now making diagnoses in individuals who wouldn't have been considered sick in the past.
Part of the explanation is technological: diagnostic tests able to detect biochemical and anatomic abnormalities that were undetectable in the past. But part of the explanation is behavioral: We look harder for things to be wrong. We test more often, we are more likely to test people who have no symptoms, and we have changed the rules about what degree of abnormality constitutes disease (a fasting blood sugar of 130 was not considered to be diabetes before 1997; now it is). ...
Diagnostic thresholds that are set too low lead in turn to a bigger problem: treatment thresholds that are too low. Diagnosis is the critical entry step into medical care — getting one tends to beget treatment. That's a big reason why we are treating millions more people for high blood pressure, diabetes, osteoporosis, glaucoma, depression, heart disease — and even cancer.
To have any hope of controlling healthcare costs, doctors will have to raise their diagnostic and treatment thresholds. And higher thresholds would be good for more than the bottom line. Less diagnosis and treatment of disease would return millions of Americans to normal, healthy lives. That's right: Higher thresholds could well improve health.
At first reading, I was a little appalled at the doctor's assertions. Surely finding the abnormalities is critical in health care. After reading further and thinking about it, I think Dr. Welch is onto something. A 65 year-old woman typically shows some loss in bone density. She also most likely has a spine which shows arthritic changes, perhaps even some 3 millimeter disc bulges in the lumbar spine. To even get to this point, however, that same woman has had some relatively extensive and expensive diagnostic tests. Then, with that diagnosis, she is now faced with treatment which may not necessarily improve her condition and may actually cause new problems (esophageal ulcers or gastrointestinal problems). If all she came into the doctor's office with were some complaints of a sore low back, one that could easily be cured with time, some rest, and a couple of aspirin, then the various diagnoses really are over the top.
As Dr. Welch points out, there are multiple reasons for these expensive diagnoses. Obviously, the technological explosion makes MRI machines readily accessible and doctors use them a lot. Second, the fear of law suits for missed diagnoses certainly plays into it. But there is more, especially in these days when "death panels" and "healthcare rationing" are phrases thrown around so readily:
The movement to measure healthcare quality, however well intended, exacerbates the problem. Many performance metrics measure whether diagnostic tests and treatments are being ordered. Because good grades typically require action, not inaction, lower thresholds are encouraged. And the advent of electronic medical records has made these actions even easier, as more and more of us have the "one-click" option to order tests and treatments.
While I am uneasy with the concept of raising the threshold for diagnosing a condition, Dr. Welch certainly has made some excellent points.
Labels: Health Care