Scans for clunkers

August 14, 2009

Three weeks ago I tried batting down a football thrown by a gifted young athlete whose pass floated higher than I could reach with both hands. The result made me appreciate how far digital imaging had come-and what was wrong with healthcare in this country.

Three weeks ago I tried batting down a football thrown by a gifted young athlete whose pass floated higher than I could reach with both hands. The result made me appreciate how far digital imaging had come-and what was wrong with healthcare in this country.

Phosphor-coated plates, scanned by a Konica computed radiography reader, delivered crystal clear images of a bone gone wrong. The middle phalanx, I learned digitally, had been struck with such force as to be knocked off the proximal phalanx.

The dislocation was far less dire than I had imagined. Moments after that errant football collided with my left hand, I noticed blood. Broken skin and a misshapen finger conjured unpleasant thoughts in the mind of my nurse, an obviously empathetic person, who stopped short of telling me what she thought might be wrong-then gave it away by wincing. With a mental picture forming of orthopedic surgery and pins sticking out of my pinky, I waited.

Relief from that concern came at the cost of less than $100: procedure code 73140TC -- "radiology-extremity." The digital radiograph was all my attending physician needed to set a course of action. A shot of local anesthetic on each side of the joint set the stage for my doc to push the middle bone back to where it should be.

I had avoided surgery-or so I thought. A couple of weeks later, my Explanation of Benefits from Empire Blue Cross Blue Shield told me that the physician had performed "surgery –bone/muscle." Empire's negotiated discounts cut the procedure charge to $595 and the office visit to $110. I did a quick tally and found that, for about 20 minutes' work, plus 10 minutes downtime for the anesthetic to take effect, my provider earned $700. In contrast, the images that clearly identified the problem and guided its solution incurred a discounted charge of $85.

Something was clearly wrong. One commission after another had been telling me and the rest of America that imaging was driving the cost of healthcare. For example, only a few months earlier, I read in the New England Journal of Medicine that imaging is among the fastest, if not the fastest, growing component of physician services covered by Medicare. It made me wonder whether, rather than focusing on imaging, maybe we should look at what patients are getting for the services they are charged for.

Relocating bones takes skill and training. But my bones were relocated in a matter of a few minutes. The charge for doing so was added to the cost of the doctor visit. What exactly did I get from the visit that was worth 110 bucks? Should I really be charged for the visit to the doctor and for the procedure, which took place during the visit? And what of the procedure itself? Is 30 minutes of anyone's time really worth $700?

One can argue persuasively that our fee-for-service system compensates providers for their knowledge as much as their time. For example, I would not consider it a deal for someone trained in, say, construction or meteorology to spend an hour or two relocating my pinky finger. But, similarly, I would not have wanted my urgent care specialist to treat me for a dislocated finger without using radiography to look inside. So why do we accept charges nearly 10 times those of imaging and then berate as wasteful the scan that made the intervention possible?

Over the last couple of years, I have found that the speed at which I ascend stairs or even just walk through the living room en route to the TV remote is directly proportional to how hard I try to keep up with my teenage sons and their friends. As I creep toward becoming a Medicare beneficiary, my right calf and left Achilles are already paying the toll for having children who play high school football and soccer.

I can hardly imagine what kinds of procedures might be charged to remedy the problems that may crop up in the future. But I'm willing to bet imaging will be the least expensive of them.