Too Many Tests!

We often hear the complaint that physicians are ordering too many tests and prescribing too many antibiotics.

Last week, I read the New York Times blog post by Pauline Chen, M.D., "Why Doctors Order So Many Tests," which highlighted a study published in the Archives of Internal Medicine. The study surveyed primary care physicians' views on health care in their own practice. Were patients receiving too little care or too much care and what were the reasons for either?

Forty percent of the physicians responding to the survey indicated that the short amount of time in the exam room was a factor in practicing more aggressively by ordering more tests or referring patients to a specialist.

In the interest of full disclosure, I am probably one of the specialists receiving referrals from primary care physicians pressed for time.

So how is this for a twist on the complaint of too many tests?

Recently my colleagues and I at the House Clinic have been told to order unnecessary tests by insurance companies and MediCal (Medicaid). Several weeks ago, I saw a young man complaining of progressive hearing loss over the past 5 years. His hearing had gotten to the point where he was having difficulty communicating in many situations. The examination of the ears was normal; his audiogram showed a conductive type of hearing loss and this was confirmed by tuning forks. The obvious diagnosis is otoslcerosis which is a condition caused by abnormal bone growth in the middle ear around the stapes bone (3rd ear bone in the middle ear). This condition is the most common cause of progressive conductive hearing loss in adults. The hearing loss is correctable by surgery in which the stapes bone is replaced by prosthesis. This is an outpatient procedure which takes less than one hour.

So, in this case I recommended surgery. We were required by the patient's insurance to get prior authorization to proceed. The insurance company told us the patient would have to get a CT scan to confirm the diagnosis. This is NOT a diagnosis that is made by CT scan. The diagnosis is based on history, examination and hearing tests. The CT scan is an unnecessary expensive test that exposes the patient to unnecessary radiation. Regardless of what the CT scan shows, the diagnosis and treatment remain the same.

In this case, the radiologist read the CT scan as normal and not showing signs of otosclerosis. We had our radiologist who specializes in the area of the ear and brain read the CT scan. Our radiologist located the otosclerosis adjacent to the stapes. The evidence of otosclerosis on the CT scan was very subtle, so it is not surprising that the general radiologist was not able to identify the pathology.

Currently, the surgery for the patient is delayed because we have to appeal the original radiologist's finding of normal. I have written a letter to the insurance company and we are awaiting the response. The patient's hearing could have already been restored.

Another frustrating example, MediCal is requiring us to obtain a neurology consult before we can order an MRI on patients who we suspect might have a tumor involving the hearing and balance nerves. The surgeons at the House Clinic are neurotologists and neurosurgeons. A neurology consult seems redundant. This requirement by MediCal is not for all patients but appears to be completely random which patients have to go to more appointments before receiving the approval for the MRI. This increases the cost of care and delays the diagnosis.

MediCal will also randomly require a full history and physical, which we do not do in our office. So the patient is sent back to their primary care physician for a physical in order to get approval for an MRI to confirm the diagnosis from one of the physicians at the House Clinic.

It seems that insurance companies are inserting themselves between the patient and the physician. This is being done as a way of reducing costs, but many times increases the cost for unnecessary tests, extra doctor visits and wasted time spent by the patient and physician.