Sunday, September 27, 2009

MSN Money: The machine that's ruining our healthcare

MSN Money has a good article about the use of MRI machines. Conservatives like to point out how the US has so many more MRI machines per capita than other countries, but that's not the whole story. Here's the most relevant first page of the article:

The main question of the national debate on health care has been who should pay for it, but lurking behind it is another one: Why does American health care cost so much in the first place? If you want an answer to that question, there's no better place to start than the proliferation of the gleaming new magnetic resonance imaging machines filling U.S. hospitals.

According to the latest data, the United States has just over one MRI scanner for every 40,000 people. That number that may not sound high, but it means that we have more than three times as many devices per person as you will find in the United Kingdom or France, and almost four times as many as in Canada. Only Japan, an MRI-happy outlier, has more.
Obviously, the MRI is an extremely useful tool, giving doctors an ability to see inside the body and diagnose conditions that would otherwise require them to probe and cut into their patients' bodies. It is also expensive to buy -- at about $2 million -- and expensive to operate. Worse, the machine is used aggressively for tests such as breast-cancer screening and yields a high rate of false positives that lead, in turn, to unnecessary surgeries.

Although MRI scanning has obvious advantages over invasive procedures, its use on the very sick is also not cost-free. When my own father was dying of cancer last year in one of New York's best hospitals, he was subjected over a period of weeks to a battery of scans. While the healthy may think of MRIs as an almost entirely benign procedure, it is not at all the same for a patient whose spine is fractured in several places from bone marrow cancer, who cannot easily lie flat, and who is hallucinating from morphine. My father came down with pneumonia from complications involving sedation for what should have been a harmless scan. In these situations, even noninvasive, seemingly harmless procedures come with risks and difficulties.

The physician and writer Atul Gawande, in an extraordinary article in The New Yorker [Editor: everyone should read this, it's really very good], detailed how doctors with a financial interest in expensive cardiac procedures have driven skyrocketing medical costs in McAllen, Texas.

Gawande demonstrates how the financial interests of doctors push patients into expensive operations of questionable usefulness. As Gawande shows, even for doctors who do not consciously seek to profit from pricy procedures, the emphasis on expensive treatments changes the norms of medical practice. And we can almost certainly add to this that it changes the expectations of patients, who come to believe that more treatment equates with better treatment.

The MRI data are a good proxy for the much more general tendency of U.S. physicians and patients to count on expensive technologies and operations.

In case after case, however, the confidence in this approach to medicine turns out to be misplaced. Whether it is the latest artificial hip, which then needs replacement itself, or an elective full body CT scan that exposes patients to radiation and leads to treatments of uncertain benefit, the reliance on technology leads to medicine that is more expensive without being better.

Editor: The McKinsey Global Institute sheds some additional light on the MRI subject in the US. (McKinsey is a well-known consulting firm.) The authors of their 2007 report, Accounting for the Cost of Health Care in the United States, point out that many MRI machines and CT scanners are acquired by outpatient clinics. These machines are very expensive, and they need a certain level of use to break even. In many other Western countries, they're centralized at hospitals.

However, the McKinsey team finds that higher prices are pervasive throughout the health care system in the US. As a result, since reimbursements are higher, the break-even volume is lower, so physicians can operate the machines (the McKinsey team calls it sub-scale operation, at least relative to the OECD countries). When you gives folks a fancy gadget, they'll use it - and it's well-documented that physicians who own an MRI machine or CT scanner will use it more than physicians who don't own one. That higher use drives total expenses up. Japan actually has more MRI machines per capita, but their reimbursements are significantly less. On a technical note, I've heard one recommendation to have the Centers for Medicare and Medicaid Services generate some formula to alter reimbursements depending on service volume. If a certain service experiences significant volume growth, it gets reimbursed less.

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