Do doctors really order unnecessary tests to make more money?
August 24, 2017 5:35 PM   Subscribe

I'm in California, first-time pregnant (over age 35), and have a platinum level Affordable Care Act (ACA) HMO plan with $0 deductible. I am really new to both medical treatment and insurance as I grew up without having any medical problems or insurance. So regular OB referred me to a specialist OB since I had expressed interest in the NIPT test (blood test for DNA for Down's syndrome, etc). The specialist OB ended up doing my anatomy scan, and he said everything looked fine. However, he also ordered a fetal echocardiogram for 2 weeks later and a follow-up ultrasound a month later. I was reading about the fetal echocardiogram and did not recognize any risk factors applying to me.

I don't mind getting it since it's just another precaution. When I asked why he ordered it, his staff said it was because I am over 35 and had declined the amnio test. Under the ACA, I was also under the impression that all prenatal visits have no co-pay, but this specialist OB office charged me a $15 co-pay and said it was because he was a "specialist." I will be calling my insurer about this. More generally, I'm wondering how common it is for doctors to order tests unnecessarily and whether they would even make more money from them (I assume from billing my insurer?)
posted by KatNips to Health & Fitness (16 answers total) 3 users marked this as a favorite
You have the right to ask why a test is being ordered. If the doctor can't explain it in a way that makes sense (beyond "well, you're over 35") you have the right to skip the test, or at least push the appointment a week or so until you get a satisfactory answer. And I'm saying this as a person who had her first child over 40, and had ALL the tests, at least the ones that made sense to me. I had CVS' done for both of my pregnancies for crying out loud. But the fact is, in our current litigious climate, doctors order every test they can to cya so that you can't come back and sue them if something is wrong with the child. Even if you don't get the test, as long as they can chart that they advised you to do so they won't be liable for damages.

As with all things, you have to be your own advocate with OBs. I will caution you, if your husband is at all the nervous type, don't let him be your plus one during doctor visits. Doctors who like to order extra tests are especially savvy at putting the fear into the husband so that the husband will do the dirty work of pressuring you to follow through with the tests.
posted by vignettist at 6:36 PM on August 24, 2017 [5 favorites]

I'm a hospital pharmacist and in my experience doctors have NO idea what things cost. They don't have to deal with the billing, and there are so many different insurances that they really can't know. Which means they make their decisions based on medical rather than financial considerations, which sounds good but can end up being kind of impractical. Like, if a fancy new heart med costs $2 per pill and works 2% better than the one that costs 10 cents a pill, is it really worth it?

I really doubt there is any financial incentive to ordering unnecessary tests. But if you think that something is going to be expensive, I would definitely talk with the doctor about it. Odds are they are not considering the cost at all.
posted by selfmedicating at 6:50 PM on August 24, 2017 [28 favorites]

Remember that "unnecessary" is a hindsight assessment. With many diagnostic tests (as opposed to procedures), the main issue is far less "ordering unnecessary tests to make more money" (on preview: selfmedicating is right that physicians are often the last to know!) than "defensively ordering expensive tests that will rarely yield anything of interest to mitigate litigation risks." You now have insurance to absorb much of the cost of this defensive medicine, and, frankly, the insurers can be well trusted to look out for themselves and will refuse coverage for what *they* consider unnecessary -- which will not always align with your definition or your doctors'. And particularly in OB-land, defensive medicine is not just motivated by fear of litigious patients -- missed calls or mistakes can be genuinely devastating to doctors, not just patients.

There are absolutely huge systemic problems with this dynamic (without even going into the myriad reasons why the tests are so damned expensive in the first instance), but you, first-time mother-to-be, are IMO fully entitled to take your choice of either getting some testing that is likely to be non-informational because you want the piece of mind and like some "extra precaution" OR pushing back as you see fit, with the possibility that your OB may (understandably) want to discuss and heavily document your refusal.

Good luck!
posted by LadyInWaiting at 6:55 PM on August 24, 2017 [1 favorite]

I think it depends to a large extent on how the doctor is employed and how that intersects with the type of insurance you have. Unless the doctor is self-employed and literally owns the fetal echo machine and does the study/interpretation himself, it is unlikely that he is making extra $$ on this test, at least not significant extra $$. More likely, he will be spending time behind the scenes arguing with your insurance company on prior authorization or peer to peer "discussion" to get them to cover the study. As a doc, I second selfmedicating's comment that we have no f-ing clue what things cost in medicine, because we don't set the price, each individual insurance company does.

Absolutely ask your doctor what extra information the fetal echo will give him to help counsel you about your risk. I was always taught that if the test or procedure doesn't help with clinical decision-making, don't order it. (I was the obnoxious resident asking if we REALLY needed to be taking three tubes of blood daily from a patient hospitalized for migraine.) I realize not all physicians practice this way, which is a shame.
posted by basalganglia at 7:04 PM on August 24, 2017 [10 favorites]

I think it's extremely rare for a doctor to deliberately, consciously order a test in order to make money, but the health system in the US is set up to encourage expensive testing. Doctors/practices/hospitals get paid for specific medical services, like tests.
posted by mskyle at 7:07 PM on August 24, 2017 [1 favorite]

You might be interested in Atul Gawande's articles about overuse and unnecessary testing. Here's the first. (There have been a couple of follow-ups.)
posted by chimpsonfilm at 7:10 PM on August 24, 2017 [5 favorites]

I don't know if you are aware that OB docs have among the highest malpractice insurance costs of all doctors partly because the parents have 18 years after the birth of a child discover a problem they think the doctor might have caused to sue. Practicing defensive medicine is a real thing, and happens because being named in a suit is a devastating event for a physician. It's more likely that this is the doctor's motive rather than benefiting financially from the testing itself. In fact, many GYN doctors used to do obstetrics, but had to stop because of the insurance premiums. My OB/GYN cousin had to join a hospital's practice to continue delivering babies for this exact reason; the hospital now covers her malpractice.

Also, if a defect is found there is an amazing amount of prenatal intervention that can be performed, so a panel of testing that would have seemed reasonable a decade ago might be inadequate now, and this probably is part of his motive. Can you ask if the tests he prescribed are recommended by the professional practice association? I think it is called ACOG (American Congress of Obstetrics and Gynocology) They will have standards for each patient situation, and if he is Board Certified he will be well informed about them.

If you are really unsure about the tests he's suggested, why not talk about them in detail?
posted by citygirl at 7:52 PM on August 24, 2017 [7 favorites]

I was 38 when Boy was born, and he starts high school this year, so it was a while back. I also refused amnio, because of the risks. They didn't do a fetal echocardiogram, but they did do a 3d ultrasound diagnostic, and oh my god, that was the coolest thing of all time.

There are apparently studios that do this sort of thing now, but at the time, it was only in hospital's diagnostics imaging centers. Anyway, if you don't have the risk factors that justify a full on echocardiagram, then maybe ask if the doctor can see what she/he is looking for with 3d imaging. Because it is so cool. So very, very cool.

Re; doctors ordering unnecessary tests; there is very little financial motivation for them to do so. They don't get paid for tests, the lab does. Doctors almost never own labs, (except in boutique surgery clinics, and those practices are designed as pure money extraction machines which specialize in vanity). I remember reading that kickbacks from auxiliary services are illegal everywhere in the US, but I'm not seeing well enough tonight to find a cite.

And as many upstream have said; OB/GYN have to practice defensively. You are considered a high risk patient by virtue of age at first birth. It sucks to get bitten by statistics, I feel your pain, I got the same bite.

Also, your insurance uses analytics software (which I have probably documented) that scan every single code in every transaction, and throws flags if something is out of the ordinary. If your doctor were ordering things outside the normal parameters of the baseline of all OB/GYNs and all patients over 35, then the authorization would have gone to a human for review. Trust me when I tell you the one thing insurance companies hate more than anything, is having money leave their hoard. If it was an unnecessary, or bill padding test, the insurance would have caught it. (This assumes your policy has pre-authorization requirements. ) Caveat 2: California Platinum policies are amazeballs, and cover much more than many other states.

Pregnancy is stressful. This test does not seem out of bounds or unreasonable given statistics and practice modalities, but You are Not being irrational or unreasonable by demanding to know just exactly what's going on with your own healthcare.

And last, Congrats! You got this. :)
posted by SecretAgentSockpuppet at 8:15 PM on August 24, 2017 [1 favorite]

It varies a lot by practice. In my training experience as an internal medicine resident at a true academic institution, we were taught to aggressively question whether a test was necessary before ordering it. There were some tests that were off-limits to order if you were not a consultant in the relevant field, and so if you had exhausted what was considered a reasonable workup, it was then and only then that you would request a consult from appropriate provider. You would relay the workup that you had already done, and discuss with the consultant or fellow (consultant-in-training) and they would see the patient and order any additional tests they felt necessary.

I am now a fellow in a hybrid academic-private practice setting, and let me tell you that private practice rules the way things get done. Specialists receive consults from other physicians that they know (in contrast to academia where whomever is scheduled in the hospital for a specialty sees the patient), and often, they will order all of the tests for a given workup, whether it is likely or not, for completeness. It is considered a courtesy to order a thorough workup the first time around, even if it is more expensive and a lot of tests will be unnecessary. It was a frustrating transition for me, because it was a totally different approach compared to my initial training, but it's a totally pervasive practice, because everybody is competing for business.

Procedures may be a different story - I'm not in a field where procedures make up much of the practice (nobody voluntarily undergoes a bone marrow biopsy unless they really, really need one).

So, I guess sometimes tests get ordered unnecessarily and providers make more money, but maybe not in the way that you might think. Providers are often able to bill for procedures on top of visits. Lab tests and imaging are less amenable to this (unless the doctor/practice owns the lab, the CT, etc.). They do make money based on the number of patients they see, and are obliged to keep referring providers happy so they continue to send them patients, so overly thorough workups do happen.

Also, in obstetrics, where the statute of limitations for birth injury may not begin until a child turns 18, I can imagine that there are different considerations of what is considered necessary in order to mitigate risk.
posted by honeybee413 at 9:35 PM on August 24, 2017 [1 favorite]

I'm a California certified nurse-midwife, so here's my two cents, some of which has already been touched upon by posters upthread. There is a wide variation in awareness/concern for costs of medications, procedures, visits, etc., as well as in training to consider cost impacts to both patient and healthcare system. Many of us are trained to consider cost of treatment/intervention, but many are not. There are also many providers who order testing based on past experience/habit or fear of litigation, rather than keeping abreast of research and providing evidence-based practice. There are also regional variations in practice and expectations for care.

Please take my next statement with the caveat that I am not an OB-bashing midwife, and consider many MDs my closest and most trusted colleagues, and that this is purely anecdotal. However, I have seen private OBs who will order unnecessary ultrasounds and testing based on flimsy risk factors, ostensibly to inflate their billing fees. (e.g., in my previous practice there was an OB who accepted my patients' insurance for scans. This OB was notorious for ordering repeat scans, echos, etc. that were not evidence-based.) In your case, being over 35 puts you at a statistically higher level for having an aneuploidy like Down syndrome, with which cardiac defects can be associated. I imagine the specialist OB ordered the echo to ensure there are no cardiac defects as the chromosome studies can't be confirmed by amnio, but I would consider this a fairly thin reason for referral in the absence of other risk factors. TINMA but I would request clarification for why the test was ordered from the physician and your regular OB, rather than relying on the information from the office staff.
posted by stillmoving at 3:06 AM on August 25, 2017 [3 favorites]

I had a urologist who would, or wouldn't, do an ultra-sound based on whether the insurance would pay for it. You can read this a couple of different ways, but it was obvious that insurance coverage affected the testing.

Note that ultra-sounds may be a special case. Some years ago, some insurance would pay for ultra-sounds done at a testing service, but not when done in the doctor's office. I don't know if this is still true at all.

At any rate, the "more tests to get more money" notion only applies when the doctor gets some benefit, either directly from doing the test or indirectly from owning the testing facility. Not true for most doctors and most tests, but true for some, including expensive ones like MRIs.
posted by SemiSalt at 6:09 AM on August 25, 2017 [1 favorite]

As someone who has a *lot* of health issues, I'll echo that doctors don't usually consider the cost. *Sometimes* they know that a medication won't be covered, and they'll give you a coupon if there's a pharma program (but that's because the pharma company told them about it). They have no idea that the pricing for things like MRI varies widely by facility. And they won't think twice about telling an in-network lab to sending your samples to a lab that's not covered by your insurance.
posted by radioamy at 10:23 AM on August 25, 2017

@radioamy - in fairness, we know that MRIs vary in price by city, but coverage levels also vary incredibly by insurance plan, and because hospitals are not transparent in their pricing, and insurance companies in their coverage, it's very difficult for a provider to ascertain cost to the patient in a given situation.
posted by honeybee413 at 3:39 PM on August 25, 2017

So several of you suggested I speak directly with the OB (specialist and regular). And I honestly don't know if this is routinely possible? The OBs tend to only physically be in the office 1-2 days a week (they also work at other offices). And although I've only been to two appointments, I had to wait 45 min-1 hour before being seen. I didn't even meet my regular OB (only joined as a patient mid-way through my pregnancy). His nurse practitioner or other staff handles the blood tests, urine tests, and basic ultrasounds. So my stupid Q is: is it a really thing to just be able to pick up the phone and talk directly to a doctor? I don't live in a big city and the doctor pickings are slim here. It also feels weird asking a doctor to speak directly to me when I wouldn't see them at the scheduled appointments since they can't bill for it....
posted by KatNips at 9:15 PM on August 25, 2017

You can schedule an appointment to have a conversation instead of scheduling a regular test, yes. You should also remember that your insurance pays for you to see a doctor, you do not have to settle for seeing a PA if that is not what you want to do (although it can make scheduling a little trickier, but then again you should be able to schedule regular visits way in advance).
posted by vignettist at 11:31 PM on August 25, 2017 [1 favorite]

To answer your update, yes it is possible to ask your doctor questions over the phone. I mean, he wouldn't be the one to actually answer the phone, but usually what happens is you leave a message with the front desk, who then transfers it back to the doc, and they call you back. They make try to route to the NP or other staff first, but you just politely say, "No, I really need to talk with Dr. Targaryen." You already got the staff version of why he ordered it, you want to understand if there is some other factor in his mind.

If the practice has a patient portal (many with electronic health records do, these days) you can also ask a question that way, secure-email style. I actually prefer this, because I can usually answer an email in a couple minutes while waiting for the next patient to get their blood pressure taken, whereas when with a phone message saying Ms. Lannister called and has some questions about the tests, it might take a couple minutes, it might take 30.
posted by basalganglia at 4:29 AM on August 26, 2017 [1 favorite]

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