WASTE AND WHAT-NOT

When I witness waste in the system, almost daily, and then listen to things like Speaker Nancy Pelosi’s speech on the proposed health care reform bill a week ago, it becomes a herculean effort to avoid succumbing to the dual demons of cynicism and resignation. Her words were like those radio commercials for one of the myriad “miracle cures” I hear every Sunday. “Guaranteed to work.” “No side effects.” Please. 

This week I got to provide a little exercise for a prisoner sent for stress testing for chest pain he’s had for years that was textbook-classic for acid reflux (“I don’t think it’s my heart, doc”) but who is at risk for coronary artery disease because he’s HIV-positive. The test, as anticipated, was negative. It seems the heightened scrutiny the penal system docs have been given over the past year is having its desired effect—contributing to the state’s bankruptcy. 

Meanwhile, over in the private sector a patient of mine who had been doing well and relocated to Bakersfield for a year had an evaluation by his new doctor 6 years post his bypass surgery. The physician was “concerned” that there had been no recent stress testing, so he obliged, irradiating him first for a “technically difficult” heart scan that showed a possible problem and then with an angiogram that showed the blood flow to his heart was intact. The patient still felt well. 

Another patient went to an emergency room in Riverside after forgetting to take his pills with him and developing chest pain related to medication withdrawal. He was appropriately evaluated and observed for threatened heart attack. He also was irradiated with a CT scan of his chest to exclude pulmonary embolism, or clot to the lungs. There’s a blood test called a D-dimer that is used to screen for clotting abnormalities seen in the presence of pulmonary embolism. I often joke it was developed by a radiologist because it has very good negative predictive value, meaning if it’s normal, you can rule out clots with a high degree of certainty. However, if it’s elevated, and minor elevations aren’t uncommon in patients visiting the ER, most of them will be false positives (meaning a lot of normal CT scans). This patient of mine had a normal D-dimer, but it didn’t save him from a chest CT. Ka-ching! 

The government is a blunt instrument when dealing with high costs driven in part by waste and in part by, well, the high cost of treating the elderly and infirm. It slashes reimbursement across the board, wounding the thoughtful, cost-effective provider and the knee-jerk or greedy diagnostician alike. 

We need a more surgical approach. Even if Nancy promises a month of free health care if I call within the next ten minutes.

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