I Wanna CT Scan Your Hand
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I Wanna CT Scan Your Hand
How the Beatles created our soaring health care costs.
By Thomas Goetz
Posted Tuesday, February 16, 2010 - 5:16pm
This is an exclusive excerpt from The Decision Tree: Taking Control of Your Health in the Era of Personalized Medicine, published this week by Rodale.
If you’re looking for a scapegoat for the escalating cost of health care—$2.5 trillion a year in the United States and climbing—you might as well blame the Beatles.
In 1931, Electric and Musical Industries, or EMI, was mostly about the M—making 78 rpm records and selling gramophones. The E was a much smaller part of the company, one in which EMI engineers worked on military technologies and dabbled in the burgeoning field of computer electronics (EMI labs helped develop radar technology and stereo sound, among other things). In 1955, the company acquired Capitol Records, with its roster of Frank Sinatra, Nat “King” Cole, and Peggy Lee, and became a powerhouse in popular music.
And in 1962, on the recommendation of EMI recording executive George Martin, the company signed a new group called the Beatles to a recording contract. Over the next decade the company earned millions of dollars from the Fab Four. It was so much money that EMI almost didn’t know what to do with it. Meanwhile, a middle-aged bachelor engineer named Godfrey Hounsfield was working at EMI’s less glamorous electronics business. Hounsfield was a skilled, unassuming scientist, quietly leading a team that built the first all-transistor computer. Flush with money broken out of teenagers’ piggy banks, EMI let Hounsfield pursue independent research.
One day in 1967—the year of Sgt. Pepper’s Lonely Hearts Club Band and Magical Mystery Tour—Hounsfield took a ramble through the English countryside and had an epiphany. By taking a picture of an object from all sides, he realized, one could create a three-dimensional image of that object. He went back to his lab and was soon taking X-rays of a cow’s head (borrowed from a nearby slaughterhouse) from all sides. By converting the images into digital files, rather than strips of film, Hounsfield discovered that a computer could reassemble dozens or hundreds of X-rays into one single image, creating a deeper look inside the head. The result was a cross-sectional, interior image with remarkable clarity. He called the technique computed tomography, or CT. As the Nobel Prize committee put it while awarding Hounsfield the Nobel Prize in Physiology or Medicine in 1979, before the CT scanner, “ordinary X-ray examinations of the head had shown the skull bones, but the brain had remained a gray, undifferentiated fog. Now, suddenly, the fog had cleared.”
First released as a clinical scanner by EMI in 1971. CT scanners started to appear at hospitals in the mid '70s. Today, there are about 30,000 in use worldwide, one-third of them in the United States.
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Submitted by gunsmoke on Wed, 02/17/2010 - 4:51pm.
Correct symptoms, wrong diagnosis
Yes the rising cost of CT machines and medicine in general is
a result of market failure. The problem though is not how CT machines are
bought or about referrals. The root cause of the market failure is the
disconnect between patient and medical practitioner when it comes to payments.
Look at LASIK. The technology has gotten better and the cost
of getting done cheaper. Why? Because it is elective and people actually pay
for it directly. Of course you could make the opposite argument that if cost
were a factor many people who do need to have a CT scan forgo it and then the
medical costs rises due to a lack of prevention. This scenario also ignores why
CT is used so often, as a previous poster noted, defensive medicine is
practiced by all physicians.
The entire medical field (nurses, doctors, hospital admins,
etc) all have CYA (cover your ass) mindset. For example was the accidental
release of medical records really that much of a problem that it now requires
such draconian handling of medical records that increases the cost of managing
those records 10-20 times what it used to? How can the “I don’t care who is
dying, you are not authorized to view his medical history” attitude not
increase the cost of medical care?
Submitted by DuckworkerMike on Wed, 02/17/2010 - 4:28pm.
Rubbish, Old Boy!
How is it that merely noting that the use of a thing has increased is sufficient evidence that a thing is overused? You might as well make the claim of the automobile-- we drive tens of thousands of miles a year (per car!) against the few hundred or so per year at the beginning of the last century. If anything, CT scans might be used less than optimal-- in the ER one time they said that a CT might help, but that waiting and seeing might be good enough and save the (minimal) radiation exposure. So we waited a few days and then the CT erevealed what we had suspected all along, a ruptured appendix. Later CTs and MRIs (years later) revealed a brain tumor (which we were afraid would be there, because of one very tiny symptom) and the results of operations to deal with it. Using imaging to see what is inside a person is far better than the alternative-- guessing at what might be wrong, or else doing "exploratory surgery". The CT is an invaluable tool for both what it reveals and what it doesn't show.
As for medicine costing more than it used to, guess what, people are living longer, dodging bullets that would have felled them prematurely, and living better quality lives. Certainly the cost of medicine has risen beyond merely infation, but that is true of education and government as well-- for sound and well-known and recognized economic reasons. Certainly there is some inefficient work in health care going on, places to reduce some costs, but the introduction and development of imaging has done an incredible amount to direct physicians, and to lessen hospital stays, and to reduce the amount of look-and-guess. Hooray, say I, for the CT and other scanners!
Submitted by Goldmakher on Wed, 02/17/2010 - 10:58am.
Overuse of imaging
Mr. Goetz is correct in saying that the overuse of imaging greatly contributes to the rising cost of medicine. Unfortunately, the typical "solution" to this problem constantly used by Medicare and private insurers is to cut reimbursement for imaging studies. This leads to lower quality imaging, without addressing the real issues that cause overuse.
There are multiple causes that drive the overuse of CT, MRI, and other imaging studies. Some of these causes are very easy to fix, but few people seem to be interested in fixing them. Some are less obvious, and the solutions will take serious thought and effort.
One cause that is easy to fix is self-referral. You don't have to be a radiologist to perform and read imaging studies (though radiologists are the most highly-trained in this). Complex studies are very demanding, and therefore well-paid. Because of this, many practices invest in a CT or MRI machine so that they can do these studies themselves and capture this revenue. The problem is that once a cardiologist has bought an expensive MRI machine, suddenly everyone who walks in the door "needs" a very expensive cardiac MRI study. There is a strong incentive to use the machine on everyone, since you have to justify its cost and get it to "pay for itself". Self-referral is a major source of twisted incentives in medicine that contribute to the market failure that Mr. Goetz identifies, and the sooner it can be done away with, the better. The problem is easy to fix by simply introducing Medicare rules (which would soon be emulated by private insurance companies) that disallow doctors to order imaging studies that they would benefit from financially. Let the cardiologists (and other clinicians) order the studies that are truly necessary for the patient, and let the radiologists perform and interpret them.
Another cause that leads to the overuse of imaging is so-called "defensive medicine". Lawyers claim that fears of malpractice do not contribute significantly to rising medical costs because actually litigating a malpractice suit is difficult and few plaintiffs actually get large awards. This view is myopic and wrongheaded. It does not address the realities of medical practice.
Imagine that you're a surgeon. A 45 year old patient comes in with abdominal pain, and other symptoms that clinically look like acute appendicitis. You are almost certain that you should just take the patient to the operating room and take out the appendix. However... what if you're wrong? If the appendix is not the cause, you might have done an unnecessary surgery (risking complications). If the appendix is the cause of the abdominal pain, but there is also a tumor growing in the liver, or an aneurysm of the abdominal aorta, or some other disorder present that will kill the patient two years later but would be detectable on a CT scan now, you'll be liable for not having ordered the CT. It does not matter what the actual chances are that you'll lose a lawsuit brought against you. Every physician has friends or colleagues who have been sued in such a situation, and had to deal with a lot of distress and expense as a result. Even if you're 99.9% sure, based on your clinical judgment, that the patient needs an appendectomy, you're going to order a CT to protect yourself.
The solution here is not as simple as that for the self-referral problem, but some kind of malpractice reform is indeed necessary. Special health courts are one excellent suggestion (http://online.wsj.com/article/SB1000142405297020448830457443285319015597...) , though trial lawyers have fought tooth and nail against them.
Yet another cause of the overuse of imaging is much harder to address because it's part of the way doctors are trained now. The mastery of diagnosis by history and physical exam are disappearing as doctors rely more and more on technology to do the problem-solving for them. The availability of the high-tech tool (an echocardiogram, for example) means that there is little incentive to spend hundreds of hours learning to hear subtle cardiac murmurs through a stethoscope. Medical students and residents are often stunned by the physical diagnosis skills of the older physician, and this is not surprising. They were trained when the high-tech tools did not exist, so they were forced to learn to do with eyes, ears, simple tools what is now routinely done by expensive machinery. The machinery genuinely enhances our ability to help the patient, but the cost is the gradual loss of the ability to do without it.
Imaging is indeed a rising part of the cost of medicine, but now that it exists, no one wants to do without it. Let's say your child in the ER, suffering from terrible abdominal pain. Will you want someone to palpate their belly, take some blood tests, and then just wait to see if it gets better (or if it gets worse to send them to the OR for exploratory laparotomy)? That's how it used to be done before all this imaging technology became available. Or will you demand the best diagnostic machinery, and costs be damned?
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