How did high-priced, questionable technology become a good cause? Entry 16 - 2008

Not long ago, I attended a charity auction raising money for a small-town hospital. The event included a high-priced charity golf tournament, several social gatherings and an auction. The event was well-attended and quite fun; everyone was excited to rally around a “good cause.”

I admit I didn’t really think about the specifics of the charity. I presumed it would provide services for people unable to pay for prenatal care or perhaps screening programs for the community at large. So, I bid happily on some smaller items in the silent auction and watched the fun as wealthy, wine-drinking bidders waged in friendly competition to buy fancy vacations and trips on private jets. Their donations—many thousands of dollars—were helping make the town a better place.

Well into the final evening event, a hospital representative began her remarks, thanking everyone for their generosity. Only when she revealed their goal did I realize what we had supported. Evidently, the money raised would go toward purchasing a $1.7M CT scan machine (otherwise known as “cat scans”) for cardiology. With pride, she announced that now their doctors could match services provided in the big city, three hours’ drive away. Certainly, she believed, lives would be saved. Around me, the crowd congratulated itself with nodding, cheers and applause.

Apparently, no one else in the room shared my dismay.

To the unfamiliar, advanced technologies for serious illnesses surely seems a worthy cause. Plus, we all have an interest in learning about the latest medical gizmos and scientific advancements. But of all the things $1.7M of donations and investments might buy to improve the well-being of 9,000 citizens, a CT scan machine should never make the list. In fact, some might argue that positioning such a device as uniformly beneficial is a stretch, at best, and perhaps fraudulent.

Put it this way: if the community was in need of transportation services, this machine is equivalent to buying a one-seat, jet-powered race car, instead of a fleet of 50 small, fuel-efficient minivans. It might help a few people in extraordinary circumstances, but for most, the choice reflects expensive and potentially dangerous over-kill.

The truth about using CT scans for cardiology (and many other exploratory procedures)? To quote from an interview in The New York Times, it is “a great technology searching for a great application.”(1) No one has proven that it diagnoses problems significantly better than technologies that are far less expensive and less risky. But lobbyists convinced Congress to reverse an effort by Medicare to pay for less expensive alternatives instead of CT scans. So, most insurance will cover the cost, which means there are few barriers to their use. Given our general tendency to believe that new means better, and expensive means higher quality, we can expect patients to demand more scans—so they can get the “best” care.

Growth in CT scans adds cost, risk and—of course—revenue.

The governments' General Accounting Office recently published a report highlighting imaging costs (which include expensive CT scans) as one of the fastest growing sources of expense in Medicare (2). Americans get 62 million CT scans each year, one-third of which could probably be substituted with an equally useful and less expensive alternative, such as x-rays (3). And the tests are not risk free; the radiation exposure from one scan is equivalent to 100 to 250 x-rays. Some researchers estimate that radiation from CT scans today could be the cause of 1-in-50 future cancers (even more when children are exposed). (4)

However, imaging can enhance revenues. From 2000 to 2006, the portion of cardiologists’ income from imaging rose from 23% to 36% (5). Once the machine is in-house, doctors and facilities have a great incentive to use it, both to cover its cost and to make a profit (6). Despite recommendations by the American Heart Association that CT scans be used in specific, limited situations (7), these machines are used increasingly for general screening, where they are touted as the only test “98% accurate in ruling out coronary artery disease” (8).

For anyone prone to worrying about what might be wrong, such technology has tremendous appeal—“just to know for sure.” Add a business trying to pay off the cost of the machine, a physician earning extra revenue, and a health plan that will cover the cost and you get incentives perfectly aligned for more scans.

So, what happens in a small town?

For certain, the CT scanner will produce:
· Greater earnings for the cardiologists and hospital (often $1,000 to $1,500 per scan).
· Higher levels of radiation exposure.
· More false positives.

And it probably will result in:
· A higher rate of scanning patients who do not have compelling symptoms.
· A higher rate of follow-up procedures, some unnecessary.

If donations covered $200K (to make the math easier), it will take 1,000 scans at $1,500 each to pay off the total cost of the machine. After that, it will be mostly profit. Some scans will be done on residents, many others on visiting tourists. Anecdotally, we hear that of many tourists who arrive in the local ER (feeling lousy due to altitude), a significant portion receive a series of tests to rule out heart problems. Now, they will have the reassurance of knowing the process of “ruling out” serious heart conditions will happen with the latest technology. And the hospital receives $1,500 from each visitor’s insurance.

More technology is not what we need.

As I watched the bidding for an all-expenses trip for four to Cancun go above $7,500, I realized that it is much easier to look to concrete, tangible machines than it is to focus on proven solutions that have a broad impact on the health of a community (described clearly by Lantz, et al., (6)), such as early childhood development, true primary care and better job opportunities. These human solutions feel so overwhelming and out-of-reach that we convince ourselves that shiny new machines can help us fix our maladies after they happen. The hospital tells me my donation improved the health of my community; I care, so I helped.

Ironically, the well-intended donations spent on a new machine may do as much harm as good, adding to the ever-increasing cost of care. Would the same townspeople have rallied around an event supporting prenatal care and strong after-school programs for youth? Probably. But sponsors and supporters of these kinds of projects are harder to find, and rarely have the kind of resources to host and organize such a fancy event.

My contribution? I did donate $100 (before I knew the purpose). You can thank me if you ever come to town and need a very detailed picture taken of your coronary arteries.

Why this matters

Unintentionally, we all contribute to a healthcare system that is overpriced and less effective than it could be. Sometimes we add to the problem directly by supporting efforts to add technology rather than basic, fundamental services. More often, we contribute simply by ignoring (or not learning about) the underlying causes of health disparities and perpetuating a belief that technology and science can cure anything.
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References

1. Berenson, A., and R. Abelson. 29 June 2008. The Evidence Gap: Weighing the Costs of a CT Scan’s Look Inside the Heart. The New York Times.

2. U.S. Government Accountability Office. 2008. Medicare Part B Imaging Services: Rapid Spending Growth and Shift to Physician Offices Indicate Need for CMS to Consider Additional Management Practices. GAO-08-452.

3. Brenner, D. J., and E. J. Hall. 2007. Computed tomography--an increasing source of radiation exposure. N Engl J Med 357, no. 22 : 2277-84. (Accessed July 31, 2008).

4. Lee, C. I., A. H. Haims, E. P. Monico, J. A. Brink, and H. P. Forman. 2004. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology 231, no. 2: 393-8.(Accessed July 31, 2008).

5. Rubenstein, S. Should Medicare Stop Medical Imaging Before It Starts? (Accessed July 31, 2008).

6. Bach, P. B. 24 July 2008. Paying Doctors to Ignore Patients. The New York Times, sec. Opinion. (Accessed July 31, 2008).

7. Bluemke, D. A., S. Achenbach, M. Budoff, T. C. Gerber, B. Gersh, L. D. Hillis, W. G. Hundley, W. J. Manning, B. F. Printz, M. Stuber, and P. K. Woodard. 2008. Noninvasive coronary artery imaging: magnetic resonance angiography and multidetector computed tomography angiography: a scientific statement from the american heart association committee on cardiovascular imaging and intervention of the council on cardiovascular radiology and intervention, and the councils on clinical cardiology and cardiovascular disease in the young. Circulation 118, no. 5: 586-606. (Accessed July 31, 2008).

8. Pulse Medical Imaging. Heart Scan. bodySCAN.m. (Accessed July 31, 2008).