walkitout (walkitout) wrote,
walkitout
walkitout

This Should Be Prosecuted as Fraud

h/t Jacob Reider, who tweeted this:

http://www.nejm.org/doi/full/10.1056/NEJMp1307295

I don't think this is anything peer reviewed; it's in the "Perspective" section. The author, Cheryl Bettigole, M.D., M.P.H., opens with this paragraph:

"The first time a patient called me to say that she'd been billed more than $600 for her Pap smear, I was sure it was a mistake. The second time, I was less sure, and these days I am no longer surprised to find laboratory charges of $1,000 or more for a test that until recently cost only $20 or $30."

The author describes the problem: it's easy for a health care provider to take the sample, check the "wrong" box, and wind up with a much higher charge than anticipated, because the "wrong" box contains a laundry list of other tests along with the Pap smear -- and a more expensive version of the Pap smear. The other tests make little sense for an asymptomatic woman coming in for a once-every-1-3 years checkup, and even _less_ sense once you figure in the cost of the test and the risk and cost of false positives.

While the author is happy about the success of the Pap smear as a screening test, it really is a lot closer to the edge in terms of cost benefit than many people realize. If you crank the cost by 50X, and add a bunch of unnecessary testing and consequent false positives and additional risk for further testing/treatment, you could tip over onto the wrong side of the cost/benefit tradeoff. Worse, if a woman comes in for a regular checkup and gets a surprise medical bill of hundreds or a thousand dollars, that money comes from somewhere if she pays it: healthy food for her or her children, money for heat or air conditioning, money for the rent or insurance, etc. And then she may decide to avoid the doctor in the future to avoid the associated financial stress.

Here is the USPSTF recommendation for pap smears:

"The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval."

Most ob/gyns and insurance companies in general try to get women in annually. I don't know why. It's pushes the false positive rate up to a point that the cost/benefit starts looking bad -- which is why the A recommendation is for every three years. More is _not_ better.

In any event, if you figure there are something like 25-33 million (roughly) women who might get a pap smear by following these recommendations in any given year, the additional money associated with the extra, let's call it $500, per test is a ton. Tens of billions of dollars a year (figure it $10-15 billion a year at the low end. I'm aiming a bit low on the number of women and on the dollars per test, since the author mentioned $1000, $600 and similar amounts for the "wrong" test).

Here's what the author concludes:

"As health care costs grow and laboratories develop savvy marketing tactics resembling those deployed by pharmaceutical companies, it is becoming increasingly clear that physicians have an obligation to be good stewards of limited resources and to understand the financial effects that the orders we write have on our patients."

I would argue that this is _exactly_ the same wrong lesson that I complained about in a previous blog post about Home Ec. If test makers have figured out they can make $10+ billion dollars a year more by parasitically charging 50x the proper amount for a basic screening test (honestly, if every woman went in annually, and they all go the "wrong" test, we'd be talking more like a hundred billion dollars), we shouldn't be going after the doctors to save money by filling out the form more carefully. That's trying to solve a problem involving bad actors by teaching people to be more wary of them.

We should be exploring criminal fraud charges against the people who sell the form and the test.

But I bet we won't, because a whole bunch of people with money to burn will look at those extra tests and only see protection and good, not false positives, and the impact on median and below income women who will be plunged further into debt.

There's a whole lot more work to be done here.
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