Testing Tribulations

When I was an internal medicine resident, one of my staff attending’s, Dr. Charles Reasner, used to ask, “What is the indication for ordering a TSH?” This is a test of thyroid function (thyroid stimulating hormone), and he was asking what reasons should one order the test. His answer was to order it if you think about it. An overactive (hyperthyroidism) or under-active  (hypothyroidism) thyroid can cause many different kinds of symptoms, treatment is relatively easy, and the test is inexpensive. Thus he said if it occurred to you to order the test, then you should do so.

Unfortunately the Centers for Medicare & Medicaid Services (CMS)does not allow us to order tests based on intuition, even though numerous studies have shown that people often make their best decisions based on reasons they can’t explain. When a quarterback such as Peyton Manning throws a football to a receiver, he first has to make the decision what to do very quickly, while a 300 pound lineman is bearing down on him. Based on prior experience he can quickly survey the field and make a decision where to throw the ball before he could make a decision based on a logical analysis. He might not be able to explain exactly why he did something, but his skill and training contributed to making the right decision seemingly without thinking.

When physicians order a test, we have to associate a diagnosis. Presumably the main purpose is to prevent wasting money for ordering tests. Although there is no benefit in ordering a PSA test for a diagnosis of glaucoma, for example, this only catches errors in the test ordered or diagnoses associated, which probably doesn’t happen often. It’s a real problem though for ordering a vitamin D level.

Medicare no longer covers a screening test for vitamin D, even though perhaps 85% of patients in the United States are deficient, treatment is cheap, and it probably saves money in the long run. Once a patient is diagnosed with osteoporosis then a level is covered, but that’s too late. Plus in men a screening bone density test is not covered, so it’s a Catch-22 situation.

At least if not that expensive, physicians should be able to order labs because they think of them. Insurance companies and the government should trust our intuition.

About Daniel Ginsberg, MD, FACP

I'm an internal medicine physician and have avidly applied computers to medicine since 1986, when I wrote my first medically oriented computer programs. So yes, that means I'm at least 35-years-old!
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2 Responses to Testing Tribulations

  1. Ronald Frederick says:

    I understand that Medicare/Medicaid and even Supplemental Insurance will not authorize tests based on the intuition of the physician. However, as a patient, I would like to hear about this intuition and given the option to pay for such a test out of pocket. I expect that CMS will become even more restrictive with all the current budgetary constraints so this situation will not improve any time soon. We appreciate hearing your thoughts on these subjects because the more information we have as patients, the better decisions we can make about our healthcare.

    • I agree in theory, but practically it’s a problem. For the same reason, patients should have the option to pay for a medication not covered by their plan if I think it’s the best choice. Unfortunately this situation happens many times every day, and it takes time to explain. I estimate it would add an hour to my already long day if I gave all my patients the chance to make such decisions. When I have tried to talk patients into getting more expensive medications they usually change their mind due to cost, or their insurance or pharmacy repeatedly trying to get them to switch. So practically I usually only offer such choices when I think there is a reasonable possibility a patient will follow my recommendation. I’m not trying to be paternalistic, but just be reasonably efficient and not make my patients feel guilty for saying no.

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