Steps toward resolving the overscanning of America

Editor’s Note: This is the second of a two-part series on the explosive growth of CAT scanning in American medical care, and what it says about our healthcare system.

Americans are the most x-rayed people in the world; the only thing getting scanned more than our bodies is our luggage at the airport. About 70 million CAT scans – the special x-rays that look inside our bodies – will be done on Americans this year, and the number increases by several million each year. Our fear of hidden disease, physicians’ fear of being sued, the fact that most of us don’t pay for our CAT scans, our aging population, and improving CAT scan technology enabling us to see more of our innermost anatomical secrets are all factors in the overscanning of America.

Many of those scans could be avoided, and, with that, millions of dollars in unnecessary health care expenditures and a lot of radiation exposure. That will take a pig pile of an effort, however, with patients, physicians, insurance companies, state legislatures, etc., all piling on to help. Without that group effort, no one alone will take all of the risk and make all of the sacrifice. Some key steps:

1. Patients have to change the way they think of CAT scans from “Why the heck not have a CAT scan” to “Doc, convince me I really need to have a CAT scan.” CAT scans have downsides that patients should consider, including cost, radiation, and incidental findings of little significance that nonetheless prompt further testing “just to be sure” some ‘spot’ on the scan means nothing;

2. Programs such as that being pioneered in Maine, New Hampshire, and Connecticut by Anthem Blue Cross to educate physicians about the radiation involved in CAT scans need to be expanded to more states and to more physicians. A presentation on the issue should be a must at the medical staff meeting of every hospital;

3. Every kind of medical insurance should make the patient pay for some portion of CAT scans and other x-rays, based perhaps on a sliding scale of income. If you are a Medicaid mom with an income below the poverty level your share of the $400 cost of a typical CAT scan might be $10, but if you are the chief medical officer of a health care system, your share might be $200. Whoever you are, though, your CAT scan should cost you something, because if you don’t have some of your financial skin in the CAT scan decision, getting a CAT scan is no financial skin off your nose;

4. We must guard against the proliferation of CAT scanners unless we can show more CAT scanners will not result in more CAT scans and more health care costs. While traditional free-market theory would suggest that price for a service drops if competition increases, this has not worked in American health care. Rather, the opposite has been true; the more providers there are of some medical services, the more demand there is for the service and price often does not drop substantially;

5. Physicians should use established, evidence-based guidelines for CAT scans where such guidelines exist, and CAT scans that do not meet such guidelines should not be paid for by insurance companies or patients. For example, there are guidelines about which patients with minor head injury should have CAT scans of the head to rule out brain injury. A physician’s ordering of CAT scans should be compared to such guidelines, and if he or she routinely does not follow them, action should be taken to change the physician’s practice if it cannot be justified after review.

6. To support such approaches, more study is needed of when CAT scans are appropriate. Where no national guidelines exist, statewide health insurers and physician groups should consider bringing together experts and developing recommendations based on existing data. Otherwise, every new study that comes out showing CAT scans can do something new will result in more scans, even if the new data is preliminary and incomplete. A good example of this is a recent study suggesting regular CAT scans of the lungs of some smokers and ex-smokers, which could result in millions more CAT scans each year looking for lung cancers;

7. State law should be developed to provide protection against malpractice lawsuits for physicians who do not order a CAT scan when the guideline suggests the patient does not need a scan. A physician who carefully follows good medical practice guidelines and therefore does not order a test should not be held liable when a patient who did not meet criteria for the test turns out to have something bad that the test would have found. That fear of getting sued by the rare patient who falls through the cracks of a good guideline is one of the main reasons physicians often ignore guidelines and order “cover-your-rear” tests.

This is difficult, boring, important work, akin to pushing warm molasses up a hill. However, if we do not get to it, our problem will not simply be too many CAT scans; it will be overuse of many new medical technologies, some of which are much more expensive. The dilemma of CAT scans is the dilemma of our unrelenting appetite for more and more high-tech health care, an appetite we cannot afford but seem unable to restrain. We have to start herding these medical cats or they are going to eat us out of house and health care.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.