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Comment by jl2718 | Hacker News Reader

Extra tests... the cost of diagnostics is a tiny fraction of the cost of doctor time, and most patients just go to the doctor to get the test. The doctor is an irellevant gatekeeper 90% of the time. How about we start talking about ‘extra’ doctor visits because patients don’t have access to tests. There are some diagnostics where this gatekeeping is literally causing a public health crisis. ‘Extra tests’ are only an issue because of the untreated disease they reveal, which costs insurers money to treat. This ‘concern’ is all part of their lobby.

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It's not entirely true that extra tests are only an issue because they reveal untreated disease that insurers would rather not pay for.

There are non-trivial false positive rates for many diagnostics that can and do lead to unnecessary follow-up tests, procedures, and emotional distress.

For example, "About half of the women getting annual mammograms over a 10-year period will have a false-positive finding." [0]

The US Task Force for Preventative Services works to clarify when diagnostics are appropriate given rates of false positives and false negatives for many different preventative services. And there are many groups that work to establish and record evidence-based guidelines for escalations of care outside of preventative care as well. Intermountain is one example.

[0] https://www.cancer.org/cancer/breast-cancer/screening-tests-...

'Extra tests' can be dangerous in a few ways: x-ray and CT scans give you a significant dose of radiation, MRIs and mammograms have high false positive rates (that can lead to painful and potentially damaging biopsies), etc. Plus there are a subset of people who are incredible hypochondriacs - if they could schedule tests directly they would have MRIs daily, convinced that the last one had missed the problem. Some people need gatekeeping.

What we need is doctors and a medical system motivated by the right things (health and wellness of the patient) rather than purely by profit and fear of lawsuits.

That is very accurate... I had an injury that I knew required specific surgery, but when I called the surgeon's office to make an appointment I was told that they only accepted referrals from family doctors, that is, I had to pay to visit a family doctor first.

This applies nowadays to most specialists as well.

I don't really consider this a problem.

Specialists are packed to the gills already and very expensive. Specialists don't want to spend time with patients who don't actually need specialized care and insurance doesn't want to pay specialists without first qualifying the issue.

I agree; however the first thing he did was to order a CT scan to confirm the diagnosis and get the exact location. So the family doctor visit was thus duplicative.

I hope the specialist didn't get a kickback from the imaging company

The US healthcare system is a raging river of money, and you can bet that every doctor, lab, hospital and other medical service has their buckets dipped into it. The entire system seems to be set up to squeeze as many billable office visits out of you as possible.

In some parts of the US, I'd be surprised if the specialist didn't own at least a share of the imaging company.

Confirming the diagnosis might or might not be prudent, depending on the injury and how likely false positives are in those sorts of injuries. Confirming the exact location shortly before the surgery? That might be prudent, especially if the damage was likely to move a bit or become worse during the waiting time. This should have been explained better.

Otherwise, I'd agree that the test was unnecessary and shouldn't be done a second time. Weirdly, it could have asily been that the first test wasn't in his particular working network - I've seen this done in hospitals before (redoing tests from places not in the hospital's network). This still isn't an issue with the referral system, though, but points to other problems.

In general I think it's a good idea. However, once someone has an ongoing medical issue that requires a certain type of specialist that gate should be left open. Keeping having to go back to your primary just to get back to the specialist you actually need is wasteful.

That's a pretty reasonable filter to have. Sure, there'll be some cases like yours where you've got enough knowledge to request a specific surgery, but for every one of those there's likely to be several "your back pain is caused by weight and posture, surgery isn't indicated" (and the occasional "why don't we see a psychiatrist about that radio the CIA put in your brain instead of a neurosurgeon...") that the GP can winnow out at a quarter of the cost and without tying up an already in-demand specialist.

This a feature, not a bug.

> The doctor is an irellevant gatekeeper 90% of the time. How about we start talking about ‘extra’ doctor visits because patients don’t have access to tests.

My primary care physician refused to order a blood draw for a generic std check. I had no cause to think that I was infected, but my partner and I agreed to get screened so we could stop using condoms (she was on birth control). I was quite offended by this overreach. This drove me away from the physician.

"‘Extra tests’ are only an issue because of the untreated disease they reveal"

This is just not true. For example, right now, there's a lot of interest in 'diagnostic test stewardship' in hospitals to avoid overtesting, because it can lead to serious problems, like causing diseases (due to treatment with antibiotics) or infections.

Similarly, false positives for cancer screenings, etc.

Yup and doctors know how to milk it for the most money. Instead of sending an email with their findings, you need another appointment just to be told what could have been said over the phone or email. Worse are checkup appointments. You get a treatment then the next time you go in for ... What exactly? To make sure that saline injection didn't kill you? It's fraud and total bullshit and wastes everyone's time. I don't blame doctors, I blame our lack of a proper healthcare system in which they need to get theirs because only certain things are billable (the phone call or email aren't). Doctors know that every trivial office visit they are making serious money. My copay is $50 for a specialist. That's for usually only a few minutes and hides the egregious sums that insurance pays. Yes, their time is valuable but so is my money and paying exorbitant amounts to see a doctor who says nothing and does nothing other than send you for a test or making sure you're still alive after your last dose of an over the counter pain reliever (I'm not making that up) is fraud, fraud we all pay for as a nation because we can't have a proper healthcare system where patients aren't used for profit and lives are saved for the sake of saving lives not lost for the sake of profits.

With medicine becoming a cartel with sprawling medical networks, the tests become synonymous with cheese on a fast food burger — an extra quarter.

We have a old school PPO plan. My wife can go to the doctor for any purpose, and sure as hell there’s a pregnancy test for $5. If you’re on a statin, you’re worth about $600/year in lab tests. Not because of insurance companies, but because the GP or NP is the top of a sales funnel. They need to drive revenue in the network as the medical networks are less efficient.

The insurance company response is urgent care clinics, which the insurance companies spent millions lobbying for. Those are great for insurance because they hand out z-packs and nebulizers and send you home. Large employers self insure drugs, so it’s a profit center for everyone. Best part for them is the 32 year old unhealthy dude stays away from the both the outrageous ER and the GP and that statin prescription.

Urgent care centers are about keeping people out of the ER--patients with medical issues that shouldn't really wait to get in with their primary, but which don't rise to ER-level issues.

Firstly, I'll caveat with this that I'm Canadian - I see different issues in my system than the for profit model. Regarding the cost - I guess that depends on the tests themselves - MRI's and CAT scans are costly machines, especially compared to 15 minutes of a doctors time. Also, how does that affect availability of that equipment for higher priority patients?

There's also the question of ethics - how invasive of a procedure does one do as an extra test before it's an issue? My wife is a sonographer - ultrasounds aren't completely diagnostic, only indicative, and a lot of the time the patient will have to go to a more extreme diagnostic to confirm. Should we be skipping the ultrasound and going straight to the biopsy every time?

> MRI's and CAT scans are costly machines, especially compared to 15 minutes of a doctors time.

I know the machines themselves are very expensive, but what are the costs to run a test? Does it draw ruinous amounts of power when running, or are there expendable materials involved?

No, but the initial investment does need to be recouped. The machines can cost into the millions.

Yes but once you have the machine, 2 people using it today or 20 makes very marginal difference.

Yup. Then it comes down to capacity - how many scans you can do a day vs. how many people need the diagnostic vs. how many people could use the diagnostic.

It's true that the investment does need to be recouped for purchasing future machines, but once you have one, it's a sunk cost.

And even then, if it's a big $5M machine [0] that lasts 10 years [1], and we generously assume it takes 1 hour per patient [2] and runs 12 hours a day, 300 days a year [3], the cost can be recouped if each test costs $140.

But an MRI bill easily costs 20 times the cost to recoup the investment.

[0]: They're usually $1-3M, and extremity scanners (hands, feet etc.) can be under $500k. [1]: The average age of an MRI machine is ~11 years, i.e. they typically last 22 years [2]: Most procedures take less than half an hour of scan time, but there's some shuffle and overhead [3]: Medicine does not run on banker's hours

Or more... $2800 would be a cheap MRI in some places... $4K+ I've seen quoted.

It's also no coincidence that companies target physicians to form "imaging cooperatives" where they finance MRI/CT/PET offering recoupment times of a year or less...

and completely by chance have higher by a Std Dev or more ordering of imaging in their private practice...

It's hard, however ethical you are, to not err on the side of sending someone to imaging when you profit linearly off of said imaging.

FWIW I'm guessing these are often purchased on borrowed money, so there may be interest to account for

Spoken by someone that does not know how medicine is practiced.

In your same line of reasoning: if you waved all your legal rights to sue the doctor, and paid for him to prescribe your tests, you would find plenty that will feel comfortable doing so!

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