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Testing Interests

Theodore Rand

Caution: too many MRIs may fatten your doctor's bank account -- and that's not good for your health.

Where do high healthcare costs come from? During their extensive training in medical school and through internship and residency, physicians are taught that the most important part of a patient visit is the taking of the medical history. That's the part where the doctor walks into the examining room, sits across from you, smiles warmly and says, "Tell me what's bothering you?" And you tell him. And he listens. As one healthcare consultant advises physicians, "taking a medical history is truly an art . . . The successful history taker is compassionate, conversational, and creative." And beyond the care aspect, the consultant adds, "the patient's history ultimately decides who pays for the visit, the patient or the insurance company" — Administrative Eyecare.

But as anyone who has visited a doctor in the last 30 or 40 years knows, the medical history process lasts seconds. I hate mentioning a purported statistic without citing the reference, but I'll do it in this one instance and hope someone out there will email me the original source: It involved a study which found that the average office visit contains 17 seconds of eye contact between patient and doctor. Whatever the exact amount of time the average medical history conversation takes, I can attest that anecdotally, based upon my experiences and those of my acquaintances whom I've polled on the matter, 17 seconds is on the long side. In short, I'd guess that doctors no longer interact with their patients in that "compassionate, conversational" way necessary for taking a good medical history.

Instead, they do "tests." As in, "Let's run some tests." Blood tests. X-Rays. CaT Scans. And, of course, the Hulk Hogan of tests, the MRI (magnetic resonance imaging). All tests, of course, cost money, lots and lots of money. And high-tech tests cost lots more. If those numbers aren't scientific enough for you, try this on for size: urine cultures (a low-tech test) start at $170. I've seen doctors (not mine, he's honest) who tell their nurses to have their patients pee in a cup before they even know which patient they're seeing. MRI scans can run upward of two grand. I know doctors who have given them to patients who've complained of headaches.

MRI scanners are big mothers; they are those clanging, tunnel-like machines you occasionally see in GE commercials, though there are dozens of other models, as well, but regardless of how they look, they cost a couple of million dollars to own and operate. Yet MRI "centers" are littering the American landscape like medical versions of McDonalds. And so are other pricey scanning modalities such as HeartCheck America, which advertises directly to consumers that they can get their arteries scanned for evidence of plaque buildup.

In terms of capability, MRIs are brilliant, they are revolutionary and potentially life-saving. They are safe, and non-invasive and open a window into the brain and organs and this is of extreme importance in the diagnosis of certain conditions. But they aren't proliferating because of need. Rather, doctors and hospitals love MRIs because they are a "revenue source", plain and simple.

On my desk is a business card for a business partnership that brings together physician investors that are interested in reaping the profits of MRI overuse. In fact, there are numerous services and consultancies that exist for the purpose of helping physicians get set up in the business of owning and operating MRIs for no other reason than to give them what Tony Soprano likes to call, "a taste" of the action. In some cases, the consultants will help set up a physician-owned "specialty" hospital — what critics refer to as "doc-in-a-box" These facilities are mills, taking in patients and running them through as many tests as they can in order to take in revenues without regard for the patients' needs.

I'm no fan of the insurance companies, but in a position paper issued last year, Blue Cross Blue Shield of Oklahoma made a good case for the claim that these freestanding imaging centers and medical facilities are a primary engine for "driving up the overall cost of health care . . ." Here's the opening paragraph from a trade magazine article directed at medical providers: "In the face of increased competition, healthcare providers are looking to generate additional revenue through ancillary services, such as diagnostic imaging. Regardless of whether it's the right strategy to enter this $36 billion market, some facilities are doing just that" — SurgiCenterOnline

And the article goes on to gently caution that there are laws designed to restrict physicians from earning such questionable profits. Still, the article concludes, "For those who want a competitive edge, diagnostic imaging might just offer a fast track to additional revenue." Those additional revenues are sweet, indeed. According to Charles Beever, an analyst with Booz Allen Hamilton, new medical technologies, of which MRIs are the most prominent, now account for $200 billion in annual costs in the US alone. That works out to about $600 million per man, woman and child. Personally, I'd rather forgo the MRI and pocket my $600 mil.

Well, I say that now, of course. The truth is, were I to potentially have a condition that could best be diagnosed by an MRI, I'd trade in the $600 million for peace-of-mind and/or health. So I don't question that MRIs provide a glimpse into the workings of the body that are available through no other means. What I do question is whether these expensive and specialized technologies are being used appropriately and sparingly. Studies that might answer that question are scarce, but one can be found going back 12 years in the New England Journal of Medicine. Researchers at that time found that more than one-third of all doctors who self-referred — that is, sent patients to MRIs in which they had profit-participation — did so without any medical basis. What's also shocking is that 28 percent of doctors who didn't self-refer also prescribed the tests unnecessarily.

What protections do you as a patient have that you won't be soaked for the one or two grand it costs to get an MRI? Sure, insurance covers some of the costs, but if you've got any sort of deductible, you can expect that the MRI fee will burn right through it, to say nothing of the greater toll on our already creaking healthcare system. So you have very little protection. There are two laws designed to restrict doctors from fraudulent overtesting; the Federal Anti-Kickback Statute and the Stark II Legislation. The first deals with doctors who receive a fee when they refer their patients to a service; the second deals with doctors who have ownership in a business or product, such as an MRI center or blood lab, from which they earn direct profits. Both laws have "safe harbor exceptions" —, meaning they have loopholes big enough to drive Mobile MRIs through.

So here's a possible path toward addressing a health care problem that is rapidly becoming a healthcare fiasco: stop the insanity of overtesting. At $1,000 to $2,000 a pop, it doesn't take an actuary to figure out where to begin cutting the fat out of our healthcare system. But nobody's done it, yet. And that is getting me to think about my own financial situation, and how to better it. Perhaps I'll attend the class," Orthopaedic MRI Ownership: Economic Advantage", offered by Proscan Imaging's "medical education foundation". Maybe I'll open up my own MRI clinic in the backyard and fatten-up my bank account.

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