Reducing the physical, mental, and financial costs of unnecessary tests and procedures

In 2018, medical waste accounted for $765 billion—or about one quarter—of health care spending in the United States. This waste, noted a ProPublica article, “contributes to health care costs that have outpaced inflation for decades, making patients and employers desperate for relief.” Unnecessary or low-effect testing and procedures make up a large portion of wasted spending on health care. Industry leaders—notably those involved in the Choose Wisely campaign—have begun taking a closer look at how primary care providers can help “patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.”

Reining in the use of unnecessary tests and procedures is an essential part of ChenMed’s value-based care model. There’s an obvious financial incentive: Reducing these interventions helps us better control the overall costs of care, which benefits our bottom line. But there’s also a health-outcomes incentive: No medical test or procedure is without risk, and as primary care providers, it’s our responsibility to ensure that we mitigate harm to our patients as best we can.

What kind of “harm” can a routine test or procedure do?

First, there’s always a risk, however minimal, to any medical procedure—even one as mundane as a blood test. Second, anytime a physician orders a test, it can cause anxiety for the patient. Therefore, it’s critical for the primary care physician to discuss both the benefits and the risks of each test or procedure with each patient before ordering anything.

Take this scenario: A primary care physician is seeing an 85-year-old patient who has asked for a prostate-specific antigen (PSA) test, which is used to diagnose prostate cancer. The physician knows that prostate cancer is a slow-growing disease. Because the patient has a projected life expectancy of about 10 years, the doctor knows that—whatever the results—the PSA test likely won’t drastically reduce that life expectancy. On the other hand, the physician knows that if they order the test and it returns a high PSA level, the patient must be referred to an oncologist for a biopsy. Biopsies which can cause adverse consequences such as bleeding, infection, and pain. Then, until the biopsy results come back, the patient will worry they may have cancer. The biopsy has a relatively high likelihood of being negative because there are several benign causes for a high PSA level in 80-something men.

Rather than mitigating adverse events, by ordering that test, the physician has opened the door to three potential harms:

• the physical cost of two non-zero-risk procedures
• the mental health cost of being anxious about potential cancer
• the financial cost of the test and the biopsy.

Physicians in situations like this usually give in, ordering testing or referring the patient to a specialist. Why?

First, the patient pressures them into it. This is one of the reasons why a strong doctor-patient relationship is so important. If the patient doesn’t trust that you’re acting in their best interest, they won’t believe you when you say a test or procedure isn’t necessary.  Second, the doctor isn’t confident in their diagnosis. Primary care medicine is an incredibly broad field. Primary care physicians may not be as strong in the specifics of, say, cardiology as they are with routine infections and injuries. When physicians encounter a scenario in which they’re not well versed, they may order tests or referrals as reassurances—they don’t want to risk being wrong and later ask, “What if?”

ChenMed care team members are not immune to this kind of second-guessing, but they have a resource that most primary care physicians do not: An internal team of specialists available for immediate consults.

ChenMed consultants are board-certified experts in top internal medicine specialties, such as cardiology, nephrology, rheumatology, endocrinology, neurology, and many more. If a ChenMed primary care provider sees something on a patient’s EKG they do not understand, they can send a message through our secure internal system to our cardiology specialists. A specialist will answer as soon as possible—sometimes before the patient leaves the center—advising the primary care provider on what next steps, if any, should be taken. These consultations help ChenMed staff reduce unnecessary testing and procedures and mitigate any physical or mental harm that may accompany those interventions.

As doctors, we have tremendous tools, particularly technology tools, at our fingertips every day. Too often, we use these tools without considering the “why” behind them or the downstream effects our decisions may produce. When we reduce our reliance on tools that do not have a clear and compelling rationale behind them, we not only mitigate potential harm to our patients but also create value that can be reinvested into alternatives that can produce better overall health outcomes. If we, as a health care industry, can redirect even a fraction of the amount of waste in our system each year, it would make a huge difference in the cost and quality of care we provide our patients. 

Learn more about ChenMed’s new internal specialist program in this article about Scott Tromanhauser, ChenMed’s first-ever chief clinical network officer.