Health Savings News - Episode 8: Testing (Part 2)

This a transcript to episode 8 of Health Savings News. In the interest of making the podcast more accessible, we will post transcripts every two weeks as episodes release.

Evan (00:08):

Hello, and welcome to Health Savings News: the podcast about healthcare costs in America and how to save money on the often expensive care all kinds of people need. I’m your host, Evan O’Connor, joined by retired doctors, Rich Sagall and Mike Woods. How’s it going?

Rich (00:22):

Good to be here.

Mike (00:23):

Yeah. Good to be here as well.

Evan (00:26):

Each episode we discuss healthcare costs in America, offer tips for saving money, and relevant news that affects and reflects the expensive landscape of healthcare in America. Today’s topic is a continuation of last episode’s conversation on testing. Last time we talked a lot about the facts and statistics necessary to understand how and why testing is done the way it is. We really recommend you listen to that for continuing on with this episode. But this time we’ll talk more about how unnecessary tests contribute billions in wasteful healthcare spending and how to avoid them to save money.

Mike (00:56):

It’s important to understand unnecessary testing. It’s important to understand how tests are chosen and how you can understand what is appropriate testing for you and your condition. Important questions to think about and ask about any test is, are they appropriate to diagnose a screen for possible conditions? You can’t always count on your healthcare professional to know the best practice for a screening or testing, and you may need to do some research on your own to find that out.

Rich (01:33):

I think we should also mention, Mike, that there is some controversy as to what is appropriate testing and it may not be a simple answer. There’s a lot of factors to take into account, which I’m sure we’ll be discussing.

Mike (01:44):

Yeah. Yep. Therefore doing the research. Follow up testing is something that you should always be suspicious of — and a lot of times it is necessary. For instance, there are some diseases that can only be monitored with testing such as thyroid disease, anticoagulation for blood clot prevention, or arrhythmias. So it’s important to know if those are being done by the best and most effective and cost effective means for testing. Again it’s important to understand how effective testing are. For instance, some forms of allergy testing are not useful at all. Sometimes a less expensive test is available. One that I commonly ran into in my own office is when physicians get a urine test for screening, a simple dip analysis is adequate for screening ytet others will send it to the lab, which will involve additional expense. When a technician has to examine the urine under a microscope which really doesn’t add anything to the test, unless you’re specifically looking for bacteria. One of the common things that we do or did as physicians is testing panels. There’s multiple reasons for that. Probably the most important one is the way that lab tests are structured. Most laboratories now combine multiple tests into one test called a profile, which includes tests four multiple things, the most common one being the metabolic profile, which includes electrolytes as well as tests for liver and kidney function. So if you are just being screened for electrolytes, do you really need the kidney and liver screening? Because as we’ve learned before that there’s a significant percentage of a false positive on any test — the more tests you get, the more likely you are to end up with a false positive — and this is enhanced by getting panels for everything and rather than getting individual tests necessary.

Rich (04:00):

I remember when I was a resident, we discussed this and it turned out in the pathology lab. They used the same machine, whether they tested for a single liver function study, let’s say, or they did the whole panel. So it really didn’t cost anymore to run the whole panel for the lab because they would do that no matter what.

Mike (04:19):

One of the most common problems we also see with testing is the concept I call overkill. And there are many reasons for that. A common example is getting a test for a condition that really doesn’t need them. The two common examples I can think of is the number of unnecessary CT scans that were done for people with simple headaches or the number of ankle x-rays for people that come to the emergency room for ankle sprains. A lot of times overkill is using a more powerful test when a simple one would be just as effective. For example, for a lot of cardiac issues cardiac ultrasound or echocardiogram is adequate, although some will opt for the more expensive heart CT or cardiac catheterization. We discussed last time — Evan was discussing some tests that really aren’t terribly useful —and I consider some of these tests that have been trendy in the past. As a pediatrician, one of the ones that I commonly came across was a recommendation to do stress exercise testing on every adolescent before participating in sports in order to allegedly discover those scant few adolescents who were at risk for cardiac arrest during exercise. Thankfully we stopped doing those and are now looking more for indications with these adolescents as to enable to zone in on the ones that actually might need it.

Rich (06:01):

I think we, we should introduce the concept of routine testing, which many doctors and patients feel unnecessary for part of a routine annual physical exam. And that’s another topic we’ll discuss in the future, but much of the routine testing turns out not to be beneficial and does not find any significant abnormalities.

Mike (06:20):

Yeah. And we’ve talked about follow up visits. The same is true with follow up tests. Q lot of them are unnecessarily obtained when it’s obvious by clinical improvement that the patient is better, but somebody wants to get those tests So they’re reassured that they’re better. Common things are repeating a complete blood count after an infection or a chest x-ray after pneumonia when most physicians do know that it takes longer to clear those or restore those to normal than it does for the patient to get better.

Rich (06:56):

Another test that I that’s interesting is the PSA, a prostate specific antigen test. I remember when this became available and very popular and everyone thought it would decrease the death rate from prostate cancer because it would be picked up early in its course. Turns out that it didn’t really make any difference and it’s not as reliable as we thought. So, as you said Mike, some tests become fad-ish and everyone wants to do them and then we realize later on that they’re not really worthwhile.

Mike (07:25):

So now that you know about how to look at your testing to figure out if it’s really appropriate for you and your situation, in two previous podcasts we’ve discussed reducing costs of medical care both by cutting down on unnecessary follow-ups and drug treatment. So here we’re gonna do the same for testing. When you look at testing, there were really two basic ways to save on testing costs. One is using your knowledge that you just gained to recognize and avoid unnecessary tests. The second way of doing this is looking around for lower cost options. A lot of times, it’s helpful to tell your provider ahead of time if this is an issue so that he can direct you in a particular direction to save money. So we’ll be discussing both of those during this episode. I’d like to start with unnecessary testing because it’s actually quite common. So let’s try to look at why this happens. One of my pet peeves associated with this is what I would like to call directed testing versus a fishing expedition. So the difference between those two is that the first of those is the directed testing, is testing based on symptoms to distinguish among a common or likely diagnosis that you might have. It’s not uncommon for some physicians — especially academic physicians — to test for all possible diagnoses, no matter how likely or rare that they are. We talked about a stepwise approach to medication in a previous episode. And that indeed is a useful way to approach testing for diagnosis that avoids the fishing expedition, where you test for the most likely diagnosis, and then expand the testing as needed. If you’re not coming up with an answer on the routine tests.

Rich (09:29):

I remember as a resident, we would be chastised if we didn’t do certain tests for completeness sake. And that would include the panels, looking for everything. Often a lot of unnecessary testing.

Mike (09:42):

Yep. So the issue became the competency of the resident and not the actual care of the patient. Yeah. Again, because that just leads right into the next point is that in many cases, diagnoses can be made without a test, but the tests are done unnecessarily for many reasons, such as it’s the standard routine “in this hospital to do this,” or in a lot of cases, unfortunately, these tests are used as a legal protector of the provider who if a lawsuit or, or a bad outcome happens, can point to something and said, “well, I got this test,” even though it was totally unnecessary at the time. I’ve also seen situations where, and again, this is especially in a hospital situation where it’s lack of patients that results in the over-testing. You can also have an approach where you try treatment first, because you have a good idea of what’s going on and then only do diagnostic testing if your treatment isn’t working. I also come across in another very common situation, which is overreading of tests. This is a situation that can definitely result in more unnecessary tests. So even if you have a test that’s important to get, if you don’t interpret it correctly and don’t look at the patient and only look at the test results you can get yourself in trouble. This is most common with imaging. I know as a provider and I know it happened to Rich as well, that radiologists are really fond of saying, “cannot rule out X, Y, Z, further testing, maybe need maybe needed to do this.” And that almost obligates you to do these tests, even if you never expected that X, Y, Z were part of the patient’s illness to begin with.

Rich (11:45):

Right. Exactly. And that can be a real problem. And people should also remember that reading imaging studies is as much an art as it is a science.

Mike (11:54):

Yeah. <Laugh> Exactly.

Rich (11:55):

Different radiologists may interpret the same study differently.

Mike (11:58):

Yeah. Rich and I are old enough to remember when we were reading our own x-rays before everything became the providence of specialists. So we’re fully aware of how difficult it can be to interpret x-rays

Evan (12:13):

More than just the interpretation of it, different machines can render different results for the same patient.

Rich (12:18):

Well, it’s also important to remember that different tests look at different things. So an x-ray may be the best to look for a bone injury would not soft tissue.

Mike (12:27):

Right. Then an MRI is best to look for soft tissue and the CTS are also good for looking at bone and more solid structures. So sometimes more often than not the practitioners do take this into account, but in a few cases, they’re sort of limited by what machines they have access to. And so, yeah, you sometimes do end up not getting the ideal study because the ideal study is not available. The way to avoid unnecessary testing is to realize that providers have been making diagnoses for centuries without tests. So like with follow up visits and medications, you really want to bring up with your provider if the test is really necessary to make the diagnosis, how it’s gonna help make the diagnosis, and if it may affect your medical care, If he can’t answer any of those questions, you probably want to have a more detailed discussion about whether the test is necessary.

Rich (13:27):

Very often a provider will say, “well, we wanna do this test to get a baseline.”

Mike (13:31):

And that is valid in a few situations, but it’s not— but again, it’s situational. The couple I can think of is when you’re having your thyroid out, you probably it’s good for you to have a baseline thyroid test. But also when you take out a thyroid your risk for damaging the parathyroid glands, which affect your calcium metabolism. So baseline calcium before a thyroidectomy also makes sense. So while they’re important, they’re only important in a very limited number of situations.

Rich (14:02):

I agree. I’ve had people say, well, let’s get an EKG. You just have a baseline. And I have to explain that whatever the EKG is now, it’s not gonna make any difference if you’re having chest pain, we’re gonna get a new one. And that’s the important one, not the baseline. And it’s probably not very predictive either.

Mike (14:19):

Exactly. Having talked about the testing, there’s another situation with unnecessary testing that I’m sure we’ve all run into. And that’s when the consultant wants to repeat the tests. Well in today’s world of patient portals and computer connection, your consultant almost always will have access to your tests. So you really need to be assertive about the tests. If all your consultant says is “I like my lab better” than that’s not a valid reason for retesting. Valid reasons for testing may be that enough time may have elapsed since the first test that it really could have changed. Your condition has changed, which may be reflected in a change in lab values. Or for some reason that center has much more accurate versions of the test. As we discussed previously, a lot of times academic centers will have more high resolution imaging studies that are superior to the ones that might be used in the community.

Rich (15:24):

Another point about testing is if you’re gonna be seeing a specialist, see if your primary care physician can order the tests that the specialist would most likely order. So that would avoid a second visit back to go over the tests.

Mike (15:37):

Yeah, exactly. I had forgot that, that they may wanna do testing cuz the primary didn’t order the correct test for that particular diagnosis. This is another important issue is getting cash prior to having an an operation. I know when I was in medical school, pre-op testing would just roll off the tongue of the surgeon, never at all thinking whether those tests are necessary. The one that most surgeons think are necessary are called the prothrombin time or partial thromboplastin time and platelet accounts. Those all are tests that look at your ability to clot. The surgeons are starting to realize that unless you actually have evidence of abnormal bleeding, doing those tests prior to surgery are not a reassurance that you’re going to clot fine and they’re not really necessary. Electrocardiograms were also routinely done for a lot of older patients when they really are only necessary for people with the history of cardiac disease or symptoms suggestive of cardiovascular disease. The same is true of an chest x-ray; those used to be common prior to all surgeries, but again, they’re totally unnecessary unless you have some symptoms that suggest active or acute lung disease. And finally there’s the complete blood count, urine analysis and electrolytes that we’ve already talked about. Again, none of these things have any benefit to this surgeon to rule out or to prove that you are not healthy enough to have surgery. If you are otherwise healthy.

Rich (17:18):

In terms of how people can save, obviously one way is avoid unnecessary testing, but there are situations where the testing is necessary and it does pay to shop around. Rather than having the doctor say, go down to my lab or the hospital’s lab and get this test done, you could ask for a written order and call a few different labs to see what it would cost. Many– not many, but some of the national labs have different programs where you can get the same test at different prices, and all you have to do is ask

Mike (17:49):

Yeah, two other hints about this. Number one is the Affordable Care Act dictated that all labs that are done as part of an annual preventive exam are fully covered. Outside of that situation, you’ll have a copay. So it’s really important to talk to your physician and make sure that the testing that they’re doing is coded such that it’s included as part of an annual checkup and ask him if there’s any other labs he thinks that might be necessary sometime in the future to do it also as part of that. So you don’t get charged. The second hint is as we’ve discussed with medications, it’s really important to understand the details of your health insurance and sticking to your network and getting prior authorizations. So like with medications the insurance company can determine if a specific test will be paid for. They can reject claims if the insurance company considers the test unnecessary or overkill. A lot of times this is determined by how your provider coded your visit, not the contents of the office note. So if you get a rejection like that, go back and make sure that your provider coded the visit appropriately.

Rich (19:15):

That would include making sure there’s a diagnosis that fits the test or the test fits the diagnosis.

Mike (19:20):

Exactly, exactly.

Rich (19:23):

Another important coding factor is whether a test is coded as diagnostic or screening, where they may pay for a screening test, such as a colonoscopy. But if the colonoscopy is being done because of bleeding, then it may fit in a different category and it may file under your deductible.

Mike (19:43):

Yeah, sometimes it’s if you’re getting some test that may be outside of routine testing, sometimes it helps to check with your insurance company ahead of time and discuss with them what test is necessary. If an upgraded test can be done and still get paid for et cetera. So a lot of these hints will help you reduce your outer pocket expenses by having the insurance company paying for a bigger proportion of the testing.

Rich (20:14):

Another issue that may come up is the frequency of testing. If you’re being followed for a certain condition such as diabetes, for example, how often do you need a hemoglobin A1C test done?

Mike (20:25):

Yeah. To follow up on Rich’s point about shopping around, there’s actually been some studies to show that you can save up to 40% of out of pocket costs for these tests, especially in those situations where your copay is a fixed percentage of the cost or you don’t have health insurance. And if you get a cost that you have gotten from a testing facility, see if they’ll put it in writing so that they can back it up. Now, just for some examples for you, as far as where to look at: freestanding radiology centers, more often than not have much less expensive MRI cat scans and other imaging tests than in hospitals. It’s common for your provider to send you to the hospital that they’re associated with, but in most cases that is the most expensive option for that test. And the same is true of medical testing facilities for blood work. The freestanding clinics are much more likely to be less expensive.

Evan (21:33):

Hospital prices are set and based on a chargemaster, which are set by the hospitals. They’re based largely on calculating discounts given to insurers. These prices are often not associated with how much products or services end up costing. Patients can be charged $7 for a single alcohol swab, $60 for one dose of an over the counter medicine. This inflation also includes routine tests and screening giving in a hospital set setting, as Mike was saying. The problem with these arbitrary prices is they’re often billed to people without insurance or who are out-of-network. These charges are commonly three times the price of people who are covered by Medicare, but some hospitals charge 10 to 20 times the Medicare price. There’s been a lot of push for transparency and pricing, whether for prescription medications advertised to the public or hospitals publishing their chargemaster prices online, but knowing the price doesn’t solve anything if the price is driven by profit or uses negotiation leverage between enormous financial entities, instead of being attributed to the cost of providing necessary care to patients.

Mike (22:35):

One reassurance for using this is that at least in this country, there is a lot of standardization and regulation about testing quality and accuracy. So you can be very certain that if you use one of these free standing facilities, you’re gonna get the same quality of results as you would get from the more expensive hospitalization. One last thing that you might never consider when it comes to medical costs is negotiating. Especially if you’re gonna be paying cash for the visit, some places will allow you to negotiate a price down to something that is a little more reasonable for you to do. And you can also ask if there’s discounts that you can do. I don’t know if there’s anything equivalent to the NeedyMeds with medications that apply to discounts, you can find for testing. Do you not? Do you know that, Rich?

Rich (23:32):

We do have one site listed as a supporter on the website that offers discounts on testing. So I would recommend people look at the website and check out that lab.

Evan (23:44):

Yeah, the NeedyMeds website also has information on diagnosis based assistance that some of them do provide assistance specifically for testing and screenings. And as you said, Mike, just to follow up on what you said about negotiating — especially in the hospital setting — where, as I said, a lot of those prices for uninsured or out-of-network patients are specifically based on what the hospital uses to negotiate the prices with insurance companies. So if you get an astoundingly high bill from a hospital, say that you won’t pay it, ask for a lower price that is more reasonable and more likely to be paid.

Rich (24:22):

I would agree with that. And you should be able to find out what other payers such as Medicare, Medicaid, or private insurance are paying for the same service.

Mike (24:32):

Yeah. So yeah, my final advice for this is when it comes to testing is do your research. Whether you’re trying to research what test is appropriate to diagnose your condition, where the least expensive place to get the test, or what tests may be cost effective, doing your research is important.

[segment break]

Evan (25:00):

The last segment of each episode. We suggest some of the culture, art entertainment, and social causes we’ve been engaged with to each other and our listeners. I have a book that I’ve been reading and I really enjoy. It’s called Fight Like Hell: The Untold History of American Labor by Kim Kelly. I’ve been a fan of Kim Kelly’s writing since she was covering heavy metal early in her career. Since becoming involved in labor after fighting for union representation in journalism, her first book chronicles the actions of marginalized people — the women, immigrants, Black people, indigenous people, LGBTQIA people, disabled people, sex workers, incarcerated people, and impoverished people — who changed the world through collective action, whose names and stories have been erased by our white patriarchal capitalist histories and how those forgotten histories connect with the intersections between gender, race, class, and labor for workers today.

Thank you so much for joining us for this episode of Health Savings News. Please subscribe, rate, and review us on Apple Podcast or wherever you’re listening to the show, it really does help. You can follow @NeedyMeds on Twitter, Facebook, Instagram, LinkedIn, YouTube, and you can follow @HealthSavingPod (no S at the end of saving) on Twitter for updates specific to this podcast and send questions, comments, and topic suggestions to podcast@needymeds.org. Our music is composed by Samuel Rulon-Miller. His music can be found at musicisadirtyword.bandcamp.com. The Health Savings News podcast is produced by me, Evan O’Connor. All the sources we used in our research can be found in the episode’s podcast description on our website or your podcast app of choice. Health Savings News is not intended to substitute for professional medical, financial, or legal advice. Always seek the advice of qualified healthcare, professional, or appropriate professional with any questions. Views expressed on Health Savings News are solely those as the individuals expressing them. Any views expressed do not necessarily represent views in health savings, news, other contributors to organization or staff. Thanks again for listening. See you in two weeks with our next episode.