Sunday, April 11, 2021

Overutilization of Colonoscopy - An Unusual Suspect

A week or so before writing this post, a patient came to my office requesting a colonoscopy.  Nothing newsworthy so far.  An individual wanted a service that our practice routinely provides.  Yet, I was reluctant to accede to her seemingly reasonable request.   She wanted a screening examination of her colon in search of a benefit that humans have pursued for as long as humans have existed – peace of mind. 

I have found that ordinary folks are often confused by the meaning of the term screening.  Screening exams can be performed on various organs of the body.  When a physician uses the term screening, it means that the patient is not having any symptoms whatsoever.  For example, if I advise a colonoscopy on a patient who is having rectal bleeding or diarrhea, this is considered a diagnostic exam, not a screening test.   

"You're paying the bill?  I'll have the steak!"

Why does this matter?  Insurance companies often reimburse screening and diagnostic exams differently.  Often, but not always, a patient’s financial obligation is higher for a diagnostic exam, when symptoms are present.   There have been occasions when a patient had contacted us after receiving the insurance company bill for a diagnostic colonoscopy, asking if we will ‘revise’ our documentation stating that the test was a screening exam.   Even an infrequent Whistleblower reader would know our response to such a request.

The patient who wanted a screening colonoscopy felt entirely well.  Her bowel pattern was unchanged.  She had no special risk factors for developing colon cancer.  My review of her record indicated that she was due for a screening colonoscopy in 3 years, not now.  I advised her of this, but she wanted to proceed anyway.

We have freedom of commerce in this country.  I can purchase goods and services according to need, desire or even whim.   If a person wishes to buy a meal, a vehicle, an appliance or a vacation, the seller’s role is not to discourage the transaction or point out that the buyer is making a foolish or unnecessary purchase.   Isn’t an individual who wants a colonoscopy, and is properly informed of the risks and benefits of the test, and is made aware that she is not yet due, entitled to the exam?

I thought that she was.  But, I didn’t think that her insurance company should pay her bill.  I explained to her that I would schedule her for the requested exam, but that she should expect that her insurance company would hold her financially responsible for the entire bill.  

Once the patient understood that the cost would be hers, she elected to wait an additional 3 years, as I originally advised.   The lesson?  When folks have skin in the game, they make different decisions.  In my view, this concept needs to be systemically incorporated into our health care system.  

If you are out to dinner at an upscale restaurant, and an insurance company would be paying the bill, would you order differently?

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