More dollars, worse care

How do we measure a doctor? Hospital length of stay? Infection rate? Flu shot compliance? Waiting time? These reality surrogates do not tell us how a patient feels or the quality of life. They are complex to measure, require major data crunching and may not focus on an individual physician. This week, two patients reminded me of a basic screening tool for good care. How much is the bill.

15 years ago, I took care of Melissa for gallbladder cancer. She received surgery, radiation and has been in remission ever since. In fact, because she has no need of a grouchy oncologist, I have not seen her in years. Melissa works full time, gets plenty of exercise and, in fact, feels quite well.

For reasons not clear to me, Melissa’s primary medical doctor ordered a cancer blood test. The test, a CEA or carcinoembryonic antigen, is used to monitor certain cancers, especially of the abdomen. The test came back mildly elevated at 7.8; normal is less than 2.5. Many patients with active cancer have CEAs in the hundreds or thousands. The physician was very concerned, so after informing the patient that it was possible, even likely, that her cancer had returned, the PMD started a workup.

First, she had a colonoscopy (+$1500) and upper endoscopy (+$2700). These were normal, which is not surprising as Melissa has no symptoms and had a clean colonoscopy three years ago. Then, a CT scan of chest, abdomen and pelvis (+$1600). Because the CT scan showed some abnormality in the region of Melissa’s previous abdominal surgery, she had a PET/CT Scan (+$3200). This last test, which is designed to detect active processes, especially cancer, anywhere in the body (nose to knees), was normal.   Finally, Melissa, frustrated, terrified, confused, exhausted, was referred back to me ($240).

8 years ago, I took care of Stan for colon cancer. He underwent surgery and chemotherapy, and has been in remission. Two years ago, he moved to Florida and despite my offer to make a house call, I have not seen him since. Stan has a robust appetite, a nasty slice and feels quite well.

Two weeks ago, Stan’s primary doctor, outside Orlando, ordered a CEA, which might make sense as this test was originally designed to monitor colon cancer. It came back mildly elevated at 6.2. Concerned, Stan’s doctor performed a critical diagnostic procedure. He called me ($2.40).

The rub is this. I told both Melissa (and subsequently her primary doctor) and Stan’s PMD, the same thing; Melissa and Stan have had mildly elevated CEAs ever since their original cancer. The blood tests were falsely positive. In these two patients CEA should not be used to screen or diagnose cancer. I recommended ignoring the test and not repeating in the future.

What intrigues me about these two cases is how hard it would be to measure the quality of care. Both patients are doing fine. Neither is in pain, has fevers or is loosing weight. Both do whatever the doctor asks. Neither would send up red flags on standard metric quality screening. However, I would propose, that one patient received excellent care and the other was harmed by excess testing, radiation, anesthesia, IV contrast, preps, and eight weeks of terror, believing she was about to die.

These two cases raise the intriguing possibility of using raw cost as a metric to screen for quality. Stan’s total bill was about $200. That was the cost of his visit with the doctor, the blood test and the phone call. Melissa’s charges? Almost 10,000 dollars.  Money not only wasted, it was used to hurt the patient.

As physicians struggle to design quality metrics, perhaps we should consider, at least as a screen for aberrancy and inferior practice, how much money we spend to take care of patients. No doubt, there are a few physicians who spend dramatically more dollars and get dramatically better results. However, I suspect that much of the time we are beyond the point where more dollars spent yield a positive correlation with quality. Rather we are often on the down slope of the bell curve and more money may mean worse care.


  • alyce
    I agree with you. There are some Doctors who love tests. I have had a few scans and finally said no more. I have had 12 weeks of radiation in my cancer career. I should glow in the dark. No more testis'
  • naufel
    Should we be testing the genes of patients non cancerous cells to compare to cancerous cells?
  • jillma
    I went through so many scans and treatment recommendations..none seemed to provide any real info..dr's or tests and treatments made everything worse. Money..finally I said..enough! Now suddenly..something has appeared at my original surgical sight...more than 10 years psychological and physiological self...totally not the same... I agree...
  • Karen Overmeyer
    Both patients are great examples of how valuable a solid Survivorship Plan of Care can be for both patient and PCPs. The patient is given a written plan which includes evidence based information particular to their own cancer. Oncology Nurses Association advocates for empowering patients and collaborating with the oncologist. Additionally, having follow up connection to a designated oncology nurse navigator is invaluable for questions and counseling. There are options which result in cost savings, emphasize continuity, and most important, provide a go- to advocate for patients and families. Oncologists could embrace nurse navigator services rather than bemoan the outcomes listed in the article. Together we could make significant impact on both controlling costs and improving quality of life for the survivor.
    • meyati
      My nurse navigator scheduled appointments for 3 specialists. Same Day- Same Time-I called her and she told me that if I didn't like it-tough. I called the head NN, and I was told that I was crazy. I have an incurable on my face-and I've heard from others in different states that they get run out, and can't get oncology care. I had trouble rescheduling, because that needed to come from my NN. I asked for another NN, i was politely, but firmly told to go to H and don't bother them anymore. So, I hounded their bosses. I now have a really good oncologist. he went over my records, Emails, and she was released. He had them monitoring her and the system. They had to sit up and fly right-correctly. And I've seen worse. If I have a problem, I see a chaplain or a social worker. Sometimes, I just need to talk-like twice a year. Then my cancer is rare, When I had a biopsy, other cancer tumors were activated and came up in 4 days, larger and more painful. I kept expressing fear of having another biopsy if the cancer comes back. Last summer, 2014, I was given the welcome news that the tumor board decided that I shouldn't have anymore biopsies, but go straight into radiation. My first question was- who pays the Nurse Navigator? The oncology unit. I told them that a person owes allegiance to whoever writes the paycheck. you know, "Where's the money?" If I moved and a nurse navigator came up, I'd have deep suspicion. They didn't even order basic lab work-to see if I had Hep, clotting time, pernicious anemia, liver function, BUN-CREATINE, HIV, nothing. I went to my PCP and demanded lab work. He told me to go to the NN. It was my birthday- I told him that Medicare allows and recommends a birthday care package- physical exam, mammogram, bone density, etc. I din't want any of those. I needed him to think of me as his mother, and order the lab that he'd want for his mother. Everyone said- Wow! That's the lab order that everyone should have. It was posted as what should and will be done. The nurse navigators should have realized that sufficient lab work wasn't being done. I began taking folic acid, and it saved me from some of the side effects.
  • meyati
    It's about ego and communication. I had to assemble my own team. When I saw a new doctor they said one of 2 things- I know him. He's willing to communicate. Or they ask if my doctors will communicate with them. After my flap in trying to get a decent Onc. I was put into the care of a delightful Sub-Saharan oncologist. At my next visit, he thanked me, because the surgeon, radiologist, and ENT reached out to him, and introduced him to the big boys club-where he had resources and support. Sometimes they fuss with each other The first time I met some of them, I asked them if they were team players, would they send records to the others? I said-Good bye- to the ones that wouldn't communicate. It's reduced scans, improved antibiotic control- they present a united front to the tumor board. My new PCP feels more relaxed. They say that they get together about every 6 weeks or so just to talk-that they can call each other about a patient- save time, and save money. They run the gamut of modern American medicine- Irish American, Saudi, Black African, Asian Indian, Italian Americans, Chinese and different beliefs and genders. Honest, some of my visits are spent on them saying how delightful the other doctors are. I had a bad PCP-and the HMO wasn't too flexible or helpful in letting escape him. I think that he said it was racist. These wonderful doctors got on the phone and called him. He got mad at me. So they banded together and got me in the system I chose the Saudi doctor. That's working out so well, that patients that need a PCP are being referred to her. While Dr. Salwitz is praising the doctor that called him up, Dr. Salwitz must be recommended for answering the phone, and sharing.
  • D Someya Reed
    @Karen Overmeyer, I apologize if this comes across as snarky (in the “sharply critical” definition) but let’s be candid, shall we? Your comment reads like a brochure for Oncology Nurse Navigators (ONN) because that’s pretty much what it is. I don’t believe you will win over many oncologists by stating that they should embrace you (as ONN) as opposed to “bemoaning” the outcomes here. Not only is there little if any bemoaning here but if you really want to read bemoaning I would suggest rereading the 2013 ‘Oncology Nurse Navigator Core Competencies’ paper for which you were a reviewer. As an example, just look at page 7, ‘Purpose of Competency Development,’ paragraph 3. Now that is “bemoaning.” Additionally, you state all the usual “brochure details” that sound good on the surface but offer no substance or explanation. For instance, the “Oncology Nurses Association advocates for empowering patients.” You don’t state with whom or how they advocate or how this has ever changed anything for any patient. You use it again when you state the ONN is a “go-to advocate for patients and families.” You have to know that this will be (mis)interpreted as being available day or night for questions and assistance and you know that’s not going to happen. That same core competencies paper includes by definition that an ONN helps patients overcome barriers to care and obtain “timely” care. How is an ONN going to do the latter with no authority over scheduling? Here are a couple of real-world examples of both. What would you, as ONN, do to resolve them or do ONNs just “facilitate” as best they can and the rest is up to the patient? 1) Patient is diagnosed as terminal without immediate surgery but just started a new job and had no coverage. Hospital will not even put patient on surgery schedule without 50% of the cost of surgery paid up front in cash. Patient asks how much that would be…hospital replies…”We won’t know until AFTER surgery.” True story. 2) Patient’s oncologist tells patient to follow explicit instructions and go into hospital through Emergency while neglecting to tell patient that costs will be 3-5 times greater for everything during entire stay in hospital because Emergency Room rates will apply throughout. Hospital does not want to admit patient here either. Lastly, another plan of care, no matter what you call it, is yet another potentially conflicting set of rules with the oncologist’s plan and the hospital discharge plan and so on. Where does the ONN get the authority to override all others and how will he/she know all that each and every patient has been told? Or, are you really saying that patients will be given “standard of care” write-ups for their specific cancer which will fulfill the “evidence based” requirement but in no way be personalized? If so, that’s not the impression imparted by your words and the industry’s materials. You know that skill levels for ONNs are all across the map and, in some cases, are not even carried out by nurses. My experiences with ONNs have proven them to be, I’m sorry to say, nothing more than glorified concierges handing out brochures that already line the walls of virtually every oncology office. You know that professional associations and societies are not in business for patients but rather the promotion of their members within their own industry. That is their primary purpose. Patients need to know this above all else because when the chips are down and things could look bad for the ONN industry, the ONN will not be allowed to assist. Rule #1 – Find out who will be there for you without question and without fail throughout your entire healthcare ordeal. There you have your only “true” advocate. The most unfortunate case of all is when your only qualified advocate is YOU. That is the problem that needs fixing the most. ONNs cannot do this and play "middle man" (person if you need a "PC" term) with the oncologists and facilities at the same time. Unfortunately their interests are not always in alignment.
  • D Someya Reed
    Just as Dr. Salwitz is stating here that throwing money at disease ensures neither quality nor cure, throwing another person on "the heap" doesn't either. (Sorry, forgot to include my wrap-up sentence to the above)
  • Joan
    When I read this I couldn't help but wonder if my sister was one of the two patients that reminded you of this. She was admitted to the hospital that week and had undergone daily radiation for 10 days. Now, I can't help but wonder what for. She would have died with or without it

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