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Colonoscopies under the microscope

Posted by John McDonough  June 4, 2013 04:41 PM

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I have been wondering if the drumbeat of public pressure on the cost of U.S. medical care would continue or abate. It's looking like it may just continue for a while.

I hope as many as possible have the chance to read the front page article in this past Sunday's New York Times on the high cost of U.S. medicine, with a particular focus on the development of colonoscopies -- The $2.7 Trillion Medical Bill. While colonoscopies account for only about $10 billion of our $2.7 trillion health spending, there's a tale to be told, and rarely has it been told so well.

Some of the highlights that struck me:

No surprise, prices for the procedure vary all over the map from a low of under $2,000 to a high as much as nearly $20,000. The only consistency is that the price of a colonoscopy everywhere in the U.S. is much higher than the price in any other industrialized nation. American exceptionalism, for sure. And not just for colonoscopies, but for any medical procedure you can name. "The U.S. just pays providers of health care much more for everything," said health expert Tom Sackville.

"The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees. ...

"Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. ...

"A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor. Many other countries deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example. ...

"Experts agree that screening for colon cancer is crucial, and a colonoscopy is intuitively appealing because it looks directly at the entire colon and doctors can remove potentially precancerous lesions that might not yet be prone to bleeding. But studies have not clearly shown that a colonoscopy prevents colon cancer or death better than the other screening methods. Indeed, some recent papers suggest that it does not, in part because early lesions may be hard to see in some parts of the colon."

Why have colonoscopies become the screening tool of choice? A big part of the answer is the money to be made:

"The Long Island center was set up with the help of a company based in Pennsylvania called Physicians Endoscopy. On its Web site, the business tells prospective physician partners that they can look forward to 'distributions averaging over $1.4 million a year to all owners, typically 100 percent return on capital investment within 18 months' and 'a return on investment of 500 percent to 2,000 percent over the initial seven years. ...

"Colonoscopies do not require general anesthesia -- a deep sleep that suppresses breathing and often requires a breathing tube. Instead, they require only 'moderate sedation,' generally with a Valium-like drug or a low dose of propofol, an intravenous medicine that takes effect quickly and wears off within minutes. In other countries, such sedative mixes are administered in offices and hospitals by a wide range of doctors and nurses for countless minor procedures, including colonoscopies. ...

"But turf battles and lobbying have helped keep anesthesiologists in the room. When propofol won the approval of the Food and Drug Administration in 1989 as an anesthesia drug, it carried a label advising that it 'should be administered only by those who are trained in the administration of general anesthesia' because of concerns that too high a dose could depress breathing and blood pressure to a point requiring resuscitation.

"Since 2005, the American College of Gastroenterology has repeatedly pressed the F.D.A. to remove or amend the restriction, arguing that gastroenterologists and their nurses are able to safely administer the drug in lower doses as a sedative. But the American Society of Anesthesiologists has aggressively lobbied for keeping the advisory, which so far the F.D.A. has done."

Everything done can justified endlessly under various definitions and interpretations of medical necessity. And so often when it matters, every important position taken by every professional group also happens to coincide with that group's economic self-interest.

The article also touches on the cost sharing patients face, often unaware, when they receive the procedure, and the bills can get awfully high -- check out the reader comments at the end of the article for numerous examples.

Here's a question, especially for fans of cost sharing: if, in fact, colon cancer screening is medically necessary for adults over age 50, what is the societal purpose behind imposing cost sharing which will only discourage many with limited resources from getting the screening?

The standard explanation is to discourage over-consumption. Is there any evidence that adults are knowingly and voluntarily lining up to get more colonoscopies than they need? Just wondering...

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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