Why Are Screening Colonoscopies So Expensive?

June 21, 2013 in Health Care "Reform", Health Policy, Medicine by RangelMD

The New York Times has tried to delve into the issue of why several common medical and surgical procedures are so expensive. They didn’t do a very good job. The NYT article spent most of the time giving the impression that US prices generally originate from greedy doctors, hospitals, and drug companies without providing much context or deeper analysis. Yet, the issue of colonoscopies is a great starting point for a primer on why American health care is so expensive.

  1. Americans have a preoccupation with technology and procedures in health care instead of consultation and collaboration with their health care providers. It is because of this that the US health care system pays it’s doctors far more to perform procedures then it does for them to be doctors. A typical gastroenterologist gets reimbursed about $150 to $250 to see a new patient and to perform a history and physical, review medical records, determine the most likely diagnoses, and formulate a treatment plan. This is called BEING A DOCTOR. But this same specialist gets paid several times this initial cost to perform a colonoscopy which might take all of 5 to 10 minutes from the time he or she enters the room to the completion of the post procedure dictation (seriously). This is why the US has so many specialists, MRI machines, hospitals, etc and expensive and excessive health care is not just limited to emergencies or complex conditions.
  2. Americans believe that when it comes to their health no expense should be be spared. Unlike basic consumer products and services, cost and volume in health care does not correlate well with quality and outcomes. The first part of the NYT article is a great example of this in which a woman underwent a screening colonoscopy in an operating room where a gastroenterologist was assisted by an anesthesiologist and a nurse. Studies have found that this procedure can be just as safely and effectively done in a medical office with minimal sedation and an office assistant but if you ask the typical American about this they will say that they prefer the more expensive option because they believe it to be “safer” or “more comfortable”. This fallacy of thought extends to just about every other aspect of health care. Patients demand antibiotics for the common cold or an MRI instead of an Xray for knee pain because they are “better”. Doctors certainly can and do try to talk their patients out of more expensive options that are not medically necessary or won’t make a difference but ultimately American’s faith in technology and procedures and their belief that more health care is always better is a far more powerful force in increasing costs than a greedy doctor or expensive hospital.
  3. Americans are comfortably insulated from the true costs of their health care. Critics like to point out that our current employer and goverment sponsored health insurance system is not transparent to the costs of health care and doesn’t respond like a true free market to control costs. But, the dirty secret is that Americans like it this way. To know the costs beforehand would suggest to many that the cheaper medical option is somehow of lower quality (see # 2 above). Americans would rather not have to deal with this knowledge especially when it comes to invasive or advanced procedures. Americans have delegated their consumer authority to the goverment and insurance companies to do the price negotiating for them. They don’t want to know how much their insurance company has contracted with a certain physician group or hospital to perform screening colonoscopies. They just want to know that the “best” gastroenterologists who work at the “best” hospital in town are included on their plan. It’s highly informative that not a single patient in the NYT article inquired beforehand about the cost of the colonoscopy – it is possible to find these prices if you look – but they only concerned themselves about the cost after their health care needs were met.
  4. There are no real incentives for either doctors or patients to reduce costs. Americans think that health care costs are too high but they feel that shopping around for the cheapest doctors and hospitals means cutting corners on the quality of their health care. They would rather not see the true costs beforehand if their insurance is going to cover the majority of it. Even if you discount the dysfunctional reimbursement system, doctors would rather err on the side of not upsetting their patients or doing something that might look bad to a medical malpractice jury and almost always this is the more expensive option. The colorectal screening exam is a great example of this. Despite only being able to examine the rectum and left side of the colon, a flexible sigmoidoscopy has been proven to be just as effective in the prevention of death from colorectal cancer as a screening colonoscopy that can examine the entire colon (if any significant polyps or other abnormalities are found on a sigmoidoscopy then this exam is followed up with a colonoscopy).  Sigmoidoscopy is safer (the risk of causing a leak in the colon is half that of a colonoscopy), can be performed in an office setting by any qualified health care provider, requires less pre-procedure patient preparation, and is cheaper than a colonoscopy. And yet colonoscopy is by far the more common screening procedure done in the US. The sigmoidoscopy does not examine half the colon and so the obvious conclusion among lay people and among doctors who might have to defend themselves in front of a medical malpractice jury made of up lay people is that because a colonoscopy is able to examine the entire colon then more is better.

The problem with articles like the one in the NYT is that it gives the impression that the rising costs of our health care are due to arbitrary cost setting by health care providers and facilities that Americans are unaware of due to the lack of cost transparency. This is simplistic at best and deceptive at worst. The reality is that this system came into being and continues to function in its current form as a result of the complacency of Americans who like their health care and like lots of it. No fundamental changes to this system are possible unless and until Americans are able to be convinced to change their perceptions of health care and to understand that more is not always better.

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