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Are insured patients an easy target for unnecessary procedures?
A recent article about usage of percutaneous coronary interventions (PCI) in the US showed that almost 70% of "non-acute" patients had private insurance, not noted as a factor in the patients needing urgent or emergency procedures:
In addition, this group of patients was often characterized by the presence of minimal coronary artery disease, and/or the lack of (appropriate) preoperative testing, optimized medical therapy or efforts at behavior modification such as cessation of smoking, diet & exercise. While one might argue that behavior modification should counseled by other physicians, certainly preoperative testing and optimized medical therapy should be part of a cardiologist's practice, being necessary steps on the way to an invasive and very expensive procedure that will require additional treatment with very expensive medications. Recent studies have found that patients often overestimate the benefits of PCI and most PCIs are performed immediately following diagnostic angiography, which limits the opportunity for informed discussions with patients about the relative benefits and risks of PCI.
This has raised concerns that financial motivations played a (considerable) role. In one particular case it has already become the target of a Senate Finance Committee investigation. Others have explained this wide-spread behavior "... as fear of malpractice suits and as the leading factor in regional variability of cardiologists’ propensity to test and treat patients..." (if they also happen to be insured).
Within the ranks of cardiology, voices of reason have counseled alternative treatments: Drs. Gibbons and Maron stated in editorials in 2007 & 2008 that physicians should replace PCI with Optimal Medical Therapy (OMT) in similar patients. They also cautioned that strong financial incentives to continue the usual use of PCI would be a substantial barrier to less profitable treatments.
I commented on this in a blog in December, 2010. Like then, I don't expect this publication will protect the public any more than the previous ones have.
- Appropriateness of Percutaneous Coronary Intervention, Chan, P. S. et al. JAMA 2011; 306:53-61
- Baucus, Grassley Outline Millions of Wasted Taxpayer Dollars, Examine Reports Of Hundreds of Improper Cardiac Stent Implantations, US Senate Commitee on Finance, December 06, 2010
- Improper Cardiac Stent Implantations: Comments on a Senate Finance report on Improper Cardiac Stent Implantations
- Variation in Cardiologists' Propensity to Test and Treat, F.L. Lucas, PhD et al. Circ Cardiovasc Qual Outcomes. 2010;3:00-00
- Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina? Raymond J. Gibbons, MD, Mayo Clinic, MedGenMed. 2007; 9(4): 49.
- Using COURAGE to Treat Angina, David J. Maron, MD, Medscape J Med. 2008; 10(12): 286.
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