Testing, Testing… $, $$, $$$

healthcare-costsIf doctors knew the exact price of expensive medical tests would they order fewer of them?

That’s exactly what Johns Hopkins researchers wanted to know.

The answer has just been published in the Journal of the American College of Radiology, and it’s a resounding: No!.  According to the investigators, revealing the costs of MRIs and other imaging tests up front had no impact on the number of tests doctors ordered for their hospitalized patients.

Cost alone does not seem to be the determining factor in deciding to go ahead with an expensive radiographic test,” says the study’s senior author, Daniel J. Brotman, M.D., director of the hospitalist program at The Johns Hopkins Hospital. “There is definitely an over-ordering of tests in this country, and we can make better decisions about whether our patients truly need each test we order for them. But when it comes to big-ticket tests like MRI, it appears the doctors have already decided they need to know the information, regardless of the cost of the test.”

MRISome earlier studies have suggested that much of the expense of laboratory tests, medical imaging and prescription drugs is unknown or hidden from providers and patients at the time of ordering, leaving financial considerations largely out of the health care decision-making process and likely driving up costs. Other studies have shown that doctors ordered fewer laboratory tests in some cases when they were given the price up front.

But, imaging tests appear to be “a different animal.”

Although there are certain inherent disincentives, aside from cost, to ordering some major tests, such as the potential danger of radiation used, physicians also need to learn how to explain to patients why they may not need them.

For the six months of the study, Brotman and his colleagues identified the 10 imaging tests most frequently ordered for patients at The Johns Hopkins Hospital. Five of these were randomly assigned to the active cost display group and 5 to the control group. During a 6-month baseline period from November 10, 2008, to May 9, 2009, no costs were displayed. During a seasonally matched period from November 2009, to May  2010, costs were displayed only for tests in the active group. At the conclusion of the study, the radiology information system was queried to determine the number of orders executed for all tests during both periods.

And, when they compared the ordering rates to the rates from a six-month period a year earlier, when no costs were displayed at all, they found no significant difference in ordering patterns.

Is this a good or a bad thing?

MRI of strokeCertainly there are many instances when expensive tests are justified. When a key diagnosis is needed there are limited options for comparison shopping.  For example, when a patient appears to have had a sub-acute stroke, an MRI is needed regardless of cost.

That is not to say there aren’t times when physicians need to look more closely at whether too many imaging tests are being ordered. Do ventilated intensive care unit patients really need a daily chest X-ray to look for potential lung problems?  Especially when there is good medical evidence that outcomes aren’t compromised if X-rays are ordered only when the patient’s condition appears to be worsening.

For too long, there has not been enough attention paid to the bottom line in health care,” Brotman says. This isn’t about rationing care to hold down costs, he says, but about choosing tests a little more wisely.

health-care-costEven though price transparency didn’t influence the way physicians ordered imaging tests in this study, financial considerations may play a role in other circumstances if tied to clinical evidence.

If you show a provider that he or she is ordering four times as many CT scans as a colleague whose patients have similar outcomes, it could change the decision-making calculus for the better.

Cost transparency must be part of the solution to solving fiscal challenges in medicine,” Brotman says. “Providers have no idea how much they’re spending. Patients don’t know either. Having everyone understand more of the economics of health care is a great place to start cutting costs in medicine.”

Seems logical to us.

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Truth Test for Knees?

Orthopedic surgeons have identified a molecular biomarker that could potentially help people with knee injuries save time, and money and the risks of surgery.

According to a study just published in The Journal of Bone and Joint Surgery researchers from California, Florida, Pennsylvania and New York have identified a biomarker found exclusively in patients with  torn cartilage.  Potentially, this simple test could help patients avoid the time and cost of undergoing an MRI and identify those who are candidates for surgery rather than those who have less operable conditions.

By analyzing the synovial fluid surrounding the knee joints of 30 patients with meniscal tears, researchers found a protein complex called fibronectin-aggrecan that wasn’t present in 10 volunteers with normal, pain-free knees.  To date, fibronectin-aggrecan has not been found in patients with osteoarthritis.

An estimated 700,000 arthroscopic knee operations are performed each year in the U.S. based on the results of MRI scans, which can cost in the region of $2,500.

While surgeons can use MRIs to try to discern the root of a patient’s knee pain, MRIs often cannot differentiate between inflammations from natural degeneration and a full-fledged tear.

Traumatic and degenerative injuries look the same on MRI,” said Gaetano Scuderi, Professor of  orthopaedic surgery at Stanford School of Medicine. “In a 50-year-old, we can’t tell the difference.”

However, correctly identifying a cartilage tear is only one obstacle. Sometimes, patients sustain pain  after corrective surgery because the tear is not actually the root of pain.

Sometimes you would think you did a great job but the patient still had pain,” Scuderi said. “Why did this  person not get better when another person did?”

Previous studies have shown that surgery is only effective for a torn meniscus or cartilage. Knee pain caused by age-related osteoarthritis or injured hip ligaments can resemble a torn meniscus but isn’t helped by surgery. This distinction isn’t always clear on MRI scans.

In a clinical setting, this new biomarker could effectively differentiate knees with pain-inducing cartilage tears that are responsive to surgery from knees with only natural cartilage degradation.

This would be especially beneficial to older patient populations in whom MRIs always show degeneration. The biomarker test offers a cheaper and more specific identification of pathology. Better still, the researchers are hoping to image the molecule non-invasively as opposed to aspirating it for assay.