MANAGED CARE December 2001. ©MediMedia USA
So, my friend is headed downtown for his total-body MRI. "How come?" say I. His wife, a radiologist, has arranged a special deal, way less than the $2,500 price her group offers the retail public. Whole-body MRI. Wow.
"Why not?" says he. "It doesn't cost my insurance anything. It's just preventive medicine at the next level."
As a physician, a health plan medical director, and a citizen, I wonder at medical diagnostic arcades proliferating like sushi bars.
Total-body scanning — first CT and, lately, MRI — has been offered to the image-conscious public for a few years now. And last summer, Quest Diagnostics launched "QuestDirect," an Internet-enabled lab boutique, where we can all order diagnostic tests from the privacy of our homes. No need to trouble your doctor. Get that Alzheimer's screening before you forget!
"What are the odds of finding anything, anyway?," my friend asks. Probability says, for every 20 tests, one result will be "out of range." That's the nature of "two standard deviations."
What to make of it?
But does out of range mean, "You're sick — quick, do something?" Not at all. Experienced clinicians learn to distinguish real findings from background noise. We've all seen anxiety-provoking "abnormal" tests that mean nothing. This is why some doctors have reservations about public-access lab testing.
Do these same factors apply to "screening MRIs?" Sure. Let's say a total-body MRI looks at 100 body parts, depending on how you define a "part." The odds are good of seeing at least something in there that makes you do a double take. (Maybe we'll finally discover how common those UFO implants are.) But, how much effort do we want to put into working up benign liver cysts? Can the radiologist avoid mentioning findings that are typically inconsequential?
I don't think our health care system is ready for the burdens that will result from public access to complex diagnostics. How prepared are we for the costs of pursuing the findings these tests generate? And, how prepared are we to see medical data increasingly become a commodity? (I carefully did not say, "medical information," a distinction I want to preserve.)
When a radiology group in Maryland first offered total body CT screening, their first 57 scans generated 27 referrals for follow-up. (Cardiology led the list.) Is this a great leap forward for preventive medicine? The story I read didn't say what the ultimate outcomes were. How much benefit resulted from this activity, as opposed to simply spinning the anxiety wheel?
Historically, every time the public wants to play doctor, the guild gets nervous. We went through this when patients got stethoscopes and otoscopes. Anyone remember when fever thermometers scandalized the profession? Home-pregnancy testing, blood-pressure and glucose monitoring also came as shocks to some physicians. But these are nothing compared to DNA screening (more than 4,000 possible diseases and counting!) that imminently is to be loosed on a public ravenous for fortune telling.
People have always looked to soothsayers and crystal-ball gazers to foretell the future. Who needs a fortune cookie that says, "You will travel" when you can get T1 weighted images of your substantia nigra? Modern medical divination is as magical as the 8-ball that served me so well through my residency (with messages such as "Concentrate and Ask Again!").
Public access to medical data makes medicine more of a commodity. This isn't automatically tragic. A personal relationship with a trusted physician (or, perhaps, a dozen trusted specialists) isn't incompatible with open access to knowledge. Yet data change how patients view their physicians. Whether we like this or not, the info genie seldom goes back into its bottle, so we have to deal with this new balance of power.
Another effect of opening the diagnostic armamentarium to the public will be to increase the counseling burden on physicians. We can't ignore patients who waltz in with a ton of film or lab printouts, any more than we can ignore patients with shopping bags full of pills. Many clinicians welcome these opportunities.
Ethical question
It also raises issues related to self-referred vs. physician-ordered testing. A busy facility might be tempted to defer less lucrative tests, regardless of clinical need, in favor of more profitable ones. This might confront radiology centers with an ethical choice between serving patients who have medical needs versus developing a potentially better-paying "cosmetic" business.
There is a good case for public safety in limiting self-prescribing of certain pharmaceuticals. But the safety argument largely fails in this area of diagnostic testing. What's the harm in self-prescription of an MRI, CT, or TSH? Aside from a little radiation or proton scrambling (assuming we can keep those pesky oxygen cylinders out of the MRI room), or an occasional mislabeled specimen, there are few physical hazards of imaging and lab. Bungee jumping presents way more social danger.
No, the risks of open diagnostics are in the information, the economics, and the continued social transformation of medicine. To argue harm, one needs to argue that knowledge is dangerous. This, of course, is true.
One only has to look at any popular delusion to see how much mischief "knowledge" can visit upon the innocent. Shall we look at cigarette ads from the 1940s? X-ray machines in shoe stores in the '50s? Fad diets in the '60s, '70s, '80s, '90s?
One client of a screening CT was quoted in the Baltimore Sun, "For $795, it's worth it to have the peace of mind." But, this guy's mind offered peace at a discount. Somebody else might need a million-dollar workup.
And peace of mind is not a likely outcome of random imaging. Many people will discover new worries — creating new agendas for care. The initial scan might not be covered, but it would be hard for most current policies to exclude the conditions that are newly discovered, benign or not. Are home biopsy kits next?
If you sprain your neck bungee jumping, your insurance will probably cover your care (unless, of course, this occurs during the course of your employment, or if you have a specific bungee exclusion, and so on...) Likewise, if your "recreational" MRI shows something amiss in your innards, your insurance will presumably be on the hook to follow up.
The argument that this is doing your insurance a favor is specious. True, early detection sometimes saves costs. But this wistful "prevention dividend" can't even be calculated, much less relied on, when we don't know the therapeutic yield of happenstance screening. Current knowledge would argue that there is no way that mass MRI screening could ever have a positive cost-benefit ratio.
In the mysterious realm of medical necessity, few such "curiosity" scans would meet the standards — until they reveal something. But we can't have a retrospective standard without setting evidence-based medicine on its head.
Finally, I'm not sure how public lab kiosks affect the credibility of physicians. It's nice to think that we're still in a highly trusted profession, although the quality of that trust has faded from its heyday in the last century. One could argue that more open communication, less paternalism, dogmatism, and quackery, broader media attention, wider availability of information, and competition from paramedical specialties all have been beneficial for physicians.
But, like all that's gone before, these new developments are going to require some adjustment on everyone's part.