ACOs and bundled payments

[SommeRiver]

And more likely to have cancer

Dude...Give me a break.

There is absolutely no reason to rule out cancer before every geriatric L3-S1 MBB, bc that's practically what you're saying you do.

Do you tell the patient that's what you're doing with the MRI?

---

Members don't see this ad.

 

[SSdoc33]

Dude...Give me a break.

There is absolutely no reason to rule out cancer before every geriatric L3-S1 MBB, bc that's practically what you're saying you do.

Do you tell the patient that's what you're doing with the MRI?

Ruling out cancer isn't the only reason.

Have you noticed that patients with severe central stenosis dont do as well with RF? I may not even do a mbb if there is severe stenosis.

If there is an old abd CT in the system, that'll do the trick as well.

 

[cowboydoc]

Ruling out cancer isn't the only reason.

Have you noticed that patients with severe central stenosis dont do as well with RF? I may not even do a mbb if there is severe stenosis.

If there is an old abd CT in the system, that'll do the trick as well.

to rule out their 2013 stenosis or malignancy?

 

[SSdoc33]

to rule out their 2013 stenosis or malignancy?

Both. Helps a little. I never said my reasoning was iron-clad

If Medicare eventually tells me I can't get an mri, I'll do the mbb. I feel a bit more protected and have a better overall sense of the problem this way

 

[deleted993114]

listen, oh learned one, i dont support single payer. your assumptions are wrong.

secondly, how many times have your had a mbb last longer than you'd think? how many times did it work when you think it shouldnt have (disc pain)? i cant always explain pain relief, but it doest follow the textbooks, thats for sure.

when the time comes that quality measures determine how i practice, then i may change. until then, ill keep saving lives and giving my patients the best treatment available.

"learned one"? no need for name calling- that is not becoming of a physician.

I am simply saying that circumstances will force you to practice evidence based medicine and comply with quality guidelines. Over ordering MRIs hurts the practice of medicine in the long run, as you are wasting valuable resources unnecessarily. Over ordering imaging is not good medicine and is neglecting your duties, as a physician, to control cost escalation which ultimately effects everyone. There are very clear reccomendations and guidelines for MRI and CT imaging of the lumbar spine, just as there are indications for any and every lab test.

Ordering imaging on everyone is a cop out and allows one to vacate reason for convenience and avoiding having to discuss why imaging is not necessary in their particular case.

Over ordering imaging IS NOT good medicine by any means and is one of the many problems associated with our healthcare system.

Additionally, I do not understand why you are associating long lasting medial branch blocks with imaging- it makes no sense at all. Ideally, in the absence of "red flags", we are ordering spine imaging for neuropathic processes, either stenosis or radiculitis, neither of which would be treated with medial branch test blocks (i.e. if you are performing test blocks, then the assumption is your are dealing with axial pain, for which you should not have needed an MRI in the first place.

What exactly are you hoping to find, using MRI, when you are treating neck or back pain the absence of "red flags"? Did your mentors encourage you to order imaging for back pain? If so, why? I simply don't understand how ordering unnecessary tests changes your treatment plan and further could lead to more unnecessary testing and treatment for asymptomatic pathology found on MRI.

 

[SSdoc33]

"learned one"? no need for name calling- that is not becoming of a physician.

I am simply saying that circumstances will force you to practice evidence based medicine and comply with quality guidelines. Over ordering MRIs hurts the practice of medicine in the long run, as you are wasting valuable resources unnecessarily. Over ordering imaging is not good medicine and is neglecting your duties, as a physician, to control cost escalation which ultimately effects everyone. There are very clear reccomendations and guidelines for MRI and CT imaging of the lumbar spine, just as there are indications for any and every lab test.

Ordering imaging on everyone is a cop out and allows one to vacate reason for convenience and avoiding having to discuss why imaging is not necessary in their particular case.

Over ordering imaging IS NOT good medicine by any means and is one of the many problems associated with our healthcare system.

You have a lot to say about imaging, but did not address the fact that you clearly addressed your comments based on prior political assumptions about me.

Nevertheless, I will defend my position on its merits.

First of all, I forget the part in the hippocratic oath where it says I have a duty to control cost escalation. Maybe it was right after the part where I pledged to treat everyone regardless of their ability to pay.

Who says I get MRI's on everyone? Never said that at all.

If i have a patient i am considering a mbb, who has failed other conservative treatments, an MRI is completely reasonable. If anything, the mri helps me limit levels or possibly gives me a reason to not perform an injection
I have already listed several other legitimate reasons why an MRI is indicated.

Also, you have a hell of a lot of nerve talking about 'cost containment' when you have openly bragged, on numerous occasions, that you put away more than 1 mil for over 20 years. Is that how you selflessly promoted the practice of cost containment in medicine?

Mic drop

 

[deleted993114]

You have a lot to say about imaging, but did not address the fact that you clearly addressed your comments based on prior political assumptions about me.

Nevertheless, I will defend my position on its merits.

First of all, I forget the part in the hippocratic oath where it says I have a duty to control cost escalation. Maybe it was right after the part where I pledged to treat everyone regardless of their ability to pay.

Who says I get MRI's on everyone? Never said that at all.

If i have a patient i am considering a mbb, who has failed other conservative treatments, an MRI is completely reasonable. If anything, the mri helps me limit levels or possibly gives me a reason to not perform an injection
I have already listed several other legitimate reasons why an MRI is indicated.

Also, you have a hell of a lot of nerve talking about 'cost containment' when you have openly bragged, on numerous occasions, that you put away more than 1 mil for over 20 years. Is that how you selflessly promoted the practice of cost containment in medicine?

Mic drop

"Also, you have a hell of a lot of nerve talking about 'cost containment' when you have openly bragged, on numerous occasions, that you put away more than 1 mil for over 20 years. Is that how you selflessly promoted the practice of cost containment in medicine?"

Wow- sounds like that hit a raw nerve. I did not put away a million dollars a year- we have these things called taxes to pay and in a state with 8% income taxes, you end up "putting away" far, far less after living expenses and taxes. I made that much money as I was associated with four neurosurgeons for whom I did all the pain work. This was also in a practice where I had 70% good commercial payers, not much medicare, and no medicaid. The high volume of procedures was "filtered" by the neurosurgeons. Iwas (by medicare relative ratings) the cheapest pain doc per patient encounter in the state. I was doing all my procedures in an office (which were necessary) and thus saved a TON of money compared to a surgery center or a hospital. Don't count other people's money- it will poison your soul.

During those years, as now, I was very judicious with imaging on those patients who did not come with imaging. In addition, I always try to order cheap meds when available. That is what I would want as a patient as well. I spent the last two years helping a large primary care group control imaging and pain costs for their ACO. It is saving them millions of dollars per year, and helped drive out of practice a pain group that did order MRIs on people with back pain and also did A LOT of unnecessary procedures that rarely worked.

Ordering MRIs for axial pain is not good practice and in the vast majority of cases is not indicated by any means. Are you seriously saying that you decide which medial branch nerve segments to block based on MRI? How in the world does an MRI dictate to you the levels that would require MBB injections??? Did you ever think about an x-ray? What if the MRI is normal, yet they had an MVA and have neck pain radiating to the traps with extension and lateral rotation? No MBBs or rf? I have never heard of someone choosing medial branch block levels by MRI- this is the first I have ever heard of this practice. Can you tell me where that is published?

If you plan to keep ordering a large amount of unnecessary imaging, you are causing more damage than good to your patient population and will be identified as a high cost provider by those controlling the ACOs. Over ordering imaging results in worse, not better, medical care for patients and leads to more unnecessary tests and potentially surgery or procedures the patient does not need. Thus, you may be a casuality of your practice style, which sounds very expensive and does not coincide with universally agreed upon imaging indications.

Don't ever complain about cuts in reimbursement, as high cost physicians and ordering a lot of unnecessary tests is a consequence of such actions.

 

[drusso]

"Also, you have a hell of a lot of nerve talking about 'cost containment' when you have openly bragged, on numerous occasions, that you put away more than 1 mil for over 20 years. Is that how you selflessly promoted the practice of cost containment in medicine?"

Wow- sounds like that hit a raw nerve. I did not put away a million dollars a year- we have these things called taxes to pay and in a state with 8% income taxes, you end up "putting away" far, far less after living expenses and taxes. I made that much money as I was associated with four neurosurgeons for whom I did all the pain work. This was also in a practice where I had 70% good commercial payers, not much medicare, and no medicaid. The high volume of procedures was "filtered" by the neurosurgeons. Iwas (by medicare relative ratings) the cheapest pain doc per patient encounter in the state. I was doing all my procedures in an office (which were necessary) and thus saved a TON of money compared to a surgery center or a hospital. Don't count other people's money- it will poison your soul.

During those years, as now, I was very judicious with imaging on those patients who did not come with imaging. In addition, I always try to order cheap meds when available. That is what I would want as a patient as well. I spent the last two years helping a large primary care group control imaging and pain costs for their ACO. It is saving them millions of dollars per year, and helped drive out of practice a pain group that did order MRIs on people with back pain and also did A LOT of unnecessary procedures that rarely worked.

Ordering MRIs for axial pain is not good practice and in the vast majority of cases is not indicated by any means. Are you seriously saying that you decide which medial branch nerve segments to block based on MRI? How in the world does an MRI dictate to you the levels that would require MBB injections??? Did you ever think about an x-ray? What if the MRI is normal, yet they had an MVA and have neck pain radiating to the traps with extension and lateral rotation? No MBBs or rf? I have never heard of someone choosing medial branch block levels by MRI- this is the first I have ever heard of this practice. Can you tell me where that is published?

If you plan to keep ordering a large amount of unnecessary imaging, you are causing more damage than good to your patient population and will be identified as a high cost provider by those controlling the ACOs. Over ordering imaging results in worse, not better, medical care for patients and leads to more unnecessary tests and potentially surgery or procedures the patient does not need. Thus, you may be a casuality of your practice style, which sounds very expensive and does not coincide with universally agreed upon imaging indications.

Don't ever complain about cuts in reimbursement, as high cost physicians and ordering a lot of unnecessary tests is a consequence of such actions.

You don't have to apologize, explain, or explain away your success. You worked hard and deserve to enjoy your rewards.

 

[hyperalgesia]

There's only one person who is sworn by oath to provide the best care to the patient. All other influences, our academic institutions, our government, our associations, are somewhat tainted by the economics of population healthcare.

Obviously we have constraints in how we practice but I just think we need to remember what our singular purpose is and stay focused. Everyone else is compromised.

 

[drusso]

nice graph drusso.

do you want doctors to essentially accept Medicaid payments? because those are what are closest to "actual" cost.

fwiw, you do know that roughly 57% of Americans have less than $1000 saved? 39% have zero saved. that $750 is roughly a weeks salary for half of all Americans....

Health Insurance Costs Surpass $20,000 Per Year, Hitting a Record

Ever-rising premiums have pushed some to drop coverage

www.bloomberg.com

Nonprofit hospital's debt collection practices draw US senator's attention

A U.S. senator is looking at how tax-exempt nonprofit hospitals collect unpaid medical bills amid recent news reports about the practices used at these organizations, according to Kaiser Health News.

www.beckershospitalreview.com

"Many Americans aren’t prepared for the risks that deductibles transfer to patients. Almost 40% of adults can’t pay an unexpected $400 expense without borrowing or selling an asset, according to a Federal Reserve survey from May. That’s a problem, Fendrick said. “My patient should not have to have a bake sale to afford her insulin,” he said."

"Unfortunately, I have seen a variety of news reports lately discussing what appear to be relentless debt-collection efforts by tax-exempt hospitals, including UVA Health System," Mr. Grassley, whose committee has power in the Senate over federal taxation matters, wrote. "These efforts raise questions about how UVA Health System and other tax-exempt hospitals are complying with" U.S. tax code requirements."

@Ducttape I feel bad for patients with those high deductible plans that get hit with $3,000 HOPD MRI charge or the $1500 HOPD CESI...it goes straight to their deductible/pocketbook. They could have paid 1/3 or less in a private practice office. Combine those high HOPD fees with the predatory collection practices of some non-profit/charity/academic hospitals and it's like literally working for the mob!

 

[SommeRiver]

I think my CESI cash price is 600.

Entire process from when you sign in until you're walking out the door is prob 30 min. Injxn is maybe 4-6 min of needle time, rarely it will go 10 min (sometimes it does bc I have a low threshold to retract and start over if it doesn't look right).

Everyone in the room has done God knows how many of these with me, so they know exactly what to do and when to do it.

It is just easier, cheaper, and I'd argue safer if it is done in my clinic.

I control every aspect of their experience, and yes it matters what the mood is like in the waiting room.

Patients already nervous about an epidural probably have an easier go at it with me in the clinic than inside a hospital...the place where people go to die according to my rural pts.

Dr Xxxxxx, if this aint scary how come I gotta go to the hospilla?

 

[callmeanesthesia]

I think my CESI cash price is 600.

Entire process from when you sign in until you're walking out the door is prob 30 min. Injxn is maybe 4-6 min of needle time, rarely it will go 10 min (sometimes it does bc I have a low threshold to retract and start over if it doesn't look right).

Everyone in the room has done God knows how many of these with me, so they know exactly what to do and when to do it.

It is just easier, cheaper, and I'd argue safer if it is done in my clinic.

I control every aspect of their experience, and yes it matters what the mood is like in the waiting room.

Patients already nervous about an epidural probably have an easier go at it with me in the clinic than inside a hospital...the place where people go to die according to my rural pts.

Dr Xxxxxx, if this aint scary how come I gotta go to the hospilla?

Agreed - the psychological aspect of it can really overinflate how “sick” people perceive themselves being if they have to go to the hospital and have injections done under IV sedation or even with full anesthesia every few months, vs a quick relatively painless shot in clinic and on their way. Also although I know some would disagree, the unsedated patient is much safer. At most I will give an oral benzo, for patients with needle phobia. Cervical epidurals are one of the least painful injections. Certainly not something to take lightly, and I am conservative in offering and performing them, but the injection itself doesn’t need to be a big production.

 

[SommeRiver]

Agreed - the psychological aspect of it can really overinflate how “sick” people perceive themselves being if they have to go to the hospital and have injections done under IV sedation or even with full anesthesia every few months, vs a quick relatively painless shot in clinic and on their way. Also although I know some would disagree, the unsedated patient is much safer. At most I will give an oral benzo, for patients with needle phobia. Cervical epidurals are one of the least painful injections. Certainly not something to take lightly, and I am conservative in offering and performing them, but the injection itself doesn’t need to be a big production.

I'll give 5mg Valium at the most.

The hospital trip or simply fentanyl + Versed makes the patient's problem larger.

 

[deleted993114]

I think my CESI cash price is 600.

Entire process from when you sign in until you're walking out the door is prob 30 min. Injxn is maybe 4-6 min of needle time, rarely it will go 10 min (sometimes it does bc I have a low threshold to retract and start over if it doesn't look right).

Everyone in the room has done God knows how many of these with me, so they know exactly what to do and when to do it.

It is just easier, cheaper, and I'd argue safer if it is done in my clinic.

I control every aspect of their experience, and yes it matters what the mood is like in the waiting room.

Patients already nervous about an epidural probably have an easier go at it with me in the clinic than inside a hospital...the place where people go to die according to my rural pts.

Dr Xxxxxx, if this aint scary how come I gotta go to the hospilla?

the office is indeed a nice, comfortable place for patients (and cheaper!). I think people are comforted when they know the office staff and find an office less intimidating than the hospital.

 

[SSdoc33]

"Also, you have a hell of a lot of nerve talking about 'cost containment' when you have openly bragged, on numerous occasions, that you put away more than 1 mil for over 20 years. Is that how you selflessly promoted the practice of cost containment in medicine?"

Wow- sounds like that hit a raw nerve. I did not put away a million dollars a year- we have these things called taxes to pay and in a state with 8% income taxes, you end up "putting away" far, far less after living expenses and taxes. I made that much money as I was associated with four neurosurgeons for whom I did all the pain work. This was also in a practice where I had 70% good commercial payers, not much medicare, and no medicaid. The high volume of procedures was "filtered" by the neurosurgeons. Iwas (by medicare relative ratings) the cheapest pain doc per patient encounter in the state. I was doing all my procedures in an office (which were necessary) and thus saved a TON of money compared to a surgery center or a hospital. Don't count other people's money- it will poison your soul.

During those years, as now, I was very judicious with imaging on those patients who did not come with imaging. In addition, I always try to order cheap meds when available. That is what I would want as a patient as well. I spent the last two years helping a large primary care group control imaging and pain costs for their ACO. It is saving them millions of dollars per year, and helped drive out of practice a pain group that did order MRIs on people with back pain and also did A LOT of unnecessary procedures that rarely worked.

Ordering MRIs for axial pain is not good practice and in the vast majority of cases is not indicated by any means. Are you seriously saying that you decide which medial branch nerve segments to block based on MRI? How in the world does an MRI dictate to you the levels that would require MBB injections??? Did you ever think about an x-ray? What if the MRI is normal, yet they had an MVA and have neck pain radiating to the traps with extension and lateral rotation? No MBBs or rf? I have never heard of someone choosing medial branch block levels by MRI- this is the first I have ever heard of this practice. Can you tell me where that is published?

If you plan to keep ordering a large amount of unnecessary imaging, you are causing more damage than good to your patient population and will be identified as a high cost provider by those controlling the ACOs. Over ordering imaging results in worse, not better, medical care for patients and leads to more unnecessary tests and potentially surgery or procedures the patient does not need. Thus, you may be a casuality of your practice style, which sounds very expensive and does not coincide with universally agreed upon imaging indications.

Don't ever complain about cuts in reimbursement, as high cost physicians and ordering a lot of unnecessary tests is a consequence of such actions.

i dont begrudge you for making a lot of money. that great. there really is no jealousy about the $$$$. it is good to know that there are those in our field who do make a lot (or used to, at least). however, i was pointing out your CLEAR hypocrisy who you spout out about cost containment.

but, since you called into question my practice, lets examine how you were able to make so much money, shall we? you were the injection monkey for 4 surgeons. you did a crap-ton of shots on essentially younger rich patients. you didnt bother to get MRIs on many of them. great job, hawkeye. stellar care

if a patient has axial pain for a year that has not responded to conservative treatment, and the xray ray is unrevealing. then what? MBB? and if that is negative, then what? nothing? an MRI can give so much info. its pretty obtuse to suggest otherwise

an mri could show a huge L4-5 facet, but 5-1 looks fine. id inject the L3 and L4 medial branches only. in the absence of trauma, a clean looking facet really shouldnt hurt

an MRI could show an annular tear and a really ugly disc -- i probably wouldt inject at all

an MRI could show a facet diastasis, pedicle stress reaction, endplate/modic changes, acute compression fracture, facet cyst, etc, etc etc. you are flying blind without it

an MRI could show renal, endometrial, prostate, thyroid, and many many other malignancies that may or may not be the cause of the back pain. its really not that uncommon.

an MRI insulates me medicolegally. at least to a certain extent.

an MRI on patients with axial pain does not make ME any money. it does not save ME time. if anything, it limits the amount of shots that i do, and actually decreases my personal remuneration. you are being disingenuous if you say that you wouldnt want an MRI before an injection. how many of us would want one 9 out of 10?

you have a point on finding these "incedentalomas". chasing all of these down is a product of the medicolegal atmosphere we are in. i cant decide to not get an MRI b/c i might find incidentalomas. i also cant decide to not get an MRI because some cowboy surgeon may operate on the findings unnecessarily. i cant control what other docs do, butthe MRI is a valuable tool if you know what you are doing.

 

[deleted993114]

i dont begrudge you for making a lot of money. that great. there really is no jealousy about the $$$$. it is good to know that there are those in our field who do make a lot (or used to, at least). however, i was pointing out your CLEAR hypocrisy who you spout out about cost containment.

but, since you called into question my practice, lets examine how you were able to make so much money, shall we? you were the injection monkey for 4 surgeons. you did a crap-ton of shots on essentially younger rich patients. you didnt bother to get MRIs on many of them. great job, hawkeye. stellar care

if a patient has axial pain for a year that has not responded to conservative treatment, and the xray ray is unrevealing. then what? MBB? and if that is negative, then what? nothing? an MRI can give so much info. its pretty obtuse to suggest otherwise

an mri could show a huge L4-5 facet, but 5-1 looks fine. id inject the L3 and L4 medial branches only. in the absence of trauma, a clean looking facet really shouldnt hurt

an MRI could show an annular tear and a really ugly disc -- i probably wouldt inject at all

an MRI could show a facet diastasis, pedicle stress reaction, endplate/modic changes, acute compression fracture, facet cyst, etc, etc etc. you are flying blind without it

an MRI could show renal, endometrial, prostate, thyroid, and many many other malignancies that may or may not be the cause of the back pain. its really not that uncommon.

an MRI insulates me medicolegally. at least to a certain extent.

an MRI on patients with axial pain does not make ME any money. it does not save ME time. if anything, it limits the amount of shots that i do, and actually decreases my personal remuneration. you are being disingenuous if you say that you wouldnt want an MRI before an injection. how many of us would want one 9 out of 10?

you have a point on finding these "incedentalomas". chasing all of these down is a product of the medicolegal atmosphere we are in. i cant decide to not get an MRI b/c i might find incidentalomas. i also cant decide to not get an MRI because some cowboy surgeon may operate on the findings unnecessarily. i cant control what other docs do, butthe MRI is a valuable tool if you know what you are doing.

Your contentions are medically incorrect and are in direct contrast to the established medical literature.

Facet arthropathy, by definition, is a bony abnormality that if one was interested in demonstrating in further detail than x-rays, one would choose a CT scan, not an MRI.

What exactly are you hoping to find on an MRI that would alter your treatment plan? I hope you understand that MRI abnormalities rarely correlate with or identify pain generators, in the absence of “red flags” or radicular pathology.

I would encourage you to examine the medical literature concerning this subject, as clearly you are practicing in opposition to the established literature. “One half assed observation of my own is than ten randomized, double blinded, prospective studies in the literature” may be your standard approach; however, I would encourage you to become more consistent with medical standards before ACOs or regulatory agencies demand your compliance.

The literature shows you are harming, not helping, patients with excessive, unnecessary imaging.

 

[SSdoc33]

Your contentions are medically incorrect and are in direct contrast to the established medical literature.

Facet arthropathy, by definition, is a bony abnormality that if one was interested in demonstrating in further detail than x-rays, one would choose a CT scan, not an MRI.

What exactly are you hoping to find on an MRI that would alter your treatment plan? I hope you understand that MRI abnormalities rarely correlate with or identify pain generators, in the absence of “red flags” or radicular pathology.

I would encourage you to examine the medical literature concerning this subject, as clearly you are practicing in opposition to the established literature. “One half assed observation of my own is than ten randomized, double blinded, prospective studies in the literature” may be your standard approach; however, I would encourage you to become more consistent with medical standards before ACOs or regulatory agencies demand your compliance.

The literature shows you are harming, not helping, patients with excessive, unnecessary imaging.

SMH. You are wrong.

Harming my patients would be ordering CTs and increasing their cancer risk.

Yes, i understand that that if there are ugly discs on an MRI, it doesnt necessarily mean that is their pain generator. thanks for the remedial spine lesson.

The MRI guidelines are set up to save money, not to improve patient care.

Frankly, the literature isn't good enough at this point. Of course an MRI will improve care. if money were no object and if we had an MRI on every patient that came in the door, your contention is that the patients would be worse off? why use any imaging at all? if fact, why do we need medications, injection, a history and a physical exam? the MRI is one data point. one piece of information used to help formulate a treatment plan. like a blood test result or a EKG.


Again, I note your preferential knit-picking, rather than taking into account the more salient points of my previous post.

 

[deleted993114]

SMH. You are wrong.

Harming my patients would be ordering CTs and increasing their cancer risk.

Yes, i understand that that if there are ugly discs on an MRI, it doesnt necessarily mean that is their pain generator. thanks for the remedial spine lesson.

The MRI guidelines are set up to save money, not to improve patient care.

Frankly, the literature isn't good enough at this point. Of course an MRI will improve care. if money were no object and if we had an MRI on every patient that came in the door, your contention is that the patients would be worse off? why use any imaging at all? if fact, why do we need medications, injection, a history and a physical exam? the MRI is one data point. one piece of information used to help formulate a treatment plan. like a blood test result or a EKG.


Again, I note your preferential knit-picking, rather than taking into account the more salient points of my previous post.

I can see there is no convincing you, despite ALL of the medical literature regarding MRI imaging refuting your practice pattern. Your over ordering imaging leads to not only increased costs of imaging, but leads to further unnecessary care. I am surprised your training program did not cover this very basic element, as it is an important aspect of imaging- when NOT to order imaging.

There are no "salient points" of your post, as it is completely factually incorrect and in contrast to the balance of good medial care, as described by the literature. Do you presume to know more than the literature or have unique insight that would make the current MRI reccommendations completely invalid?

I am afraid you will not listen to reason or the facts of the literature, and will continue to practice as you are, so a discussion with you is somewhat pointless. I can reference dozens of articles describing proper MRI indications and you would ignore all of them and will continue to do as you wish.

 

[hyperalgesia]

I can see there is no convincing you, despite ALL of the medical literature regarding MRI imaging refuting your practice pattern. Your over ordering imaging leads to not only increased costs of imaging, but leads to further unnecessary care. I am surprised your training program did not cover this very basic element, as it is an important aspect of imaging- when NOT to order imaging.

There are no "salient points" of your post, as it is completely factually incorrect and in contrast to the balance of good medial care, as described by the literature. Do you presume to know more than the literature or have unique insight that would make the current MRI reccommendations completely invalid?

I am afraid you will not listen to reason or the facts of the literature, and will continue to practice as you are, so a discussion with you is somewhat pointless. I can reference dozens of articles describing proper MRI indications and you would ignore all of them and will continue to do as you wish.

From just an individual patient care perspective, it seems like your argument against MRIs is the probability of unnecessary care. I think it's a good point but may apply more to PCPs, who really don't know how to interpret the findings and educate the patient.

I'm not sure it's too much information that's the problem. I think we should address the reasons why docs defensively hunt down every incidentaloma.

 

[drusso]

I can see there is no convincing you...

Welcome to my world. Some people are blinded by ideology and can't/won't see what's obvious.

 

[deleted993114]

Welcome to my world. Some people are blinded by ideology and can't/won't see what's obvious.

Indeed- there are simply some individuals who insist they are correct, despite all evidence to the contrary. This is neither prudent nor compatible with rational medical care.

It is one thing to adhere to a practice pattern or recommend a treatment in which it may be controversial, but there is SOME EVIDENCE to support it. However, when essentially ALL of the medical literature opposes a particular view (such as MRIs for benign back pain), one would assume that the practitioner is simply recalcitrant and not amendable to reason or the available fund of medical knowledge.

When one divorces oneself from standardized and recommended practice, one is, by definition, practicing outside the realm of conventional medicine. To do so is to practice at one's own peril and compromises the care of patients who have entrusted their faith in the judgement of the physician.

 

[SSdoc33]

Indeed- there are simply some individuals who insist they are correct, despite all evidence to the contrary. This is neither prudent nor compatible with rational medical care.

It is one thing to adhere to a practice pattern or recommend a treatment in which it may be controversial, but there is SOME EVIDENCE to support it. However, when essentially ALL of the medical literature opposes a particular view (such as MRIs for benign back pain), one would assume that the practitioner is simply recalcitrant and not amendable to reason or the available fund of medical knowledge.

When one divorces oneself from standardized and recommended practice, one is, by definition, practicing outside the realm of conventional medicine. To do so is to practice at one's own peril and compromises the care of patients who have entrusted their faith in the judgement of the physician.

Ugh. Rather than spouting off the same crap, why dont you add to the conversation and post an article defending your point. I'll do your homework for you once I finish putting out some fires over here

 

[10KHertz]

Most Cigna plans require and updated MRI every year for an ESI approval, regardless of outcomes.

More and more BCBS plans (many variations per state) require yearly repeat Mbbs even if a RFA lasts over a year.

We have no say in the matter really....Why argue.

 

[SSdoc33]

Welcome to my world. Some people are blinded by ideology and can't/won't see what's obvious.

this is the sort of collectivist, government-run rationing that you typically rail against. its pretty embarrassing how you would pivot like this

 

[SSdoc33]

who among us would NOT want to see his/own MRI before a MBB? anyone? i doubt it

like i said, ill get to the literature when i have the time, but im sure to run into some meta-analysis by Chou. is that where you want to hang your hat, Hawkeye? he is basically the anti-christ on this board

 

[drusso]

this is the sort of collectivist, government-run rationing that you typically rail against. its pretty embarrassing how you would pivot like this

We wouldn't need collectivist, government-run rationing if we just let health markets, perhaps with some very light regulation to protect patient safety, do their own thing. MRI's are a non-invasive imaging modality. Let them eat cake.

 

[SSdoc33]

We wouldn't need collectivist, government-run rationing if we just let health markets, perhaps with some very light regulation to protect patient safety, do their own thing. MRI's are a non-invasive imaging modality. Let them eat cake.

Probably the most reasonable thing you've said in years

 

[drusso]

Probably the most reasonable thing you've said in years

My wife says I haven't changed a bit...

 

[lobelsteve]

MR I associated with worse outcomes for back pain.

 

[SSdoc33]

MR I associated with worse outcomes for back pain.

Would you want one before a mbb on your back?

 

[SommeRiver]

Would you want one before an mri on your back?

Hey man...You can't deny MRI of the back results in over utilization of resources. Everyone over the age of 40 has something "injectable" on an MRI.

I think everyone understands the gist of what you're saying but your argument is based on the assumption you're saving lives while others are not.

You're not catching anything that we're missing.

Edit - Your Q wasn't directed at me but I'll answer...I do NOT want an MRI on my back. Why? I don't have back pain and the last thing I need to know is that I have stenosis and severe spondylosis bc now I have a "problem" that is going to be in the back of my mind forever...If I see you for LBP refractory to conservative measures and time I want an XRAY, and if you see standard things I want you to do standard things for me.

Axial pain doesn't need an MRI to treat.

You can MRI me after the facet CSI doesn't work, and the delay in imaging at that point is minimal.

 

[SSdoc33]

Hey man...You can't deny MRI of the back results in over utilization of resources. Everyone over the age of 40 has something "injectable" on an MRI.

I think everyone understands the gist of what you're saying but your argument is based on the assumption you're saving lives while others are not.

You're not catching anything that we're missing.

Edit - Your Q wasn't directed at me but I'll answer...I do NOT want an MRI on my back. Why? I don't have back pain and the last thing I need to know is that I have stenosis and severe spondylosis bc now I have a "problem" that is going to be in the back of my mind forever...If I see you for LBP refractory to conservative measures and time I want an XRAY, and if you see standard things I want you to do standard things for me.

Axial pain doesn't need an MRI to treat.

You can MRI me after the facet CSI doesn't work, and the delay in imaging at that point is minimal.

i appreciate your "olive branch" approach. much more effective than others.

while it is true that the delay in MRI could be minimal, who knows what happens to that patient. maybe they dont f/u after the MBB. maybe the MBB is equivocal. maybe you end with an RF and your back still hurts. at that point, you are 3 injections, several months, and a lot more money spent when an MRI up front could have prevented all of it.

i definitely can see both sides. patients get really pissed when you dont order an MRI, and when someone else invariably does it it shows badness, you are up sh$ts creek. the patients dont get to dictate care, and i routinely refuse MRIs when the patients want them, but this scenario is on my mind.

 

[SSdoc33]

MR I associated with worse outcomes for back pain.

Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes - PubMed

The majority of cases had no early MRI indications. Results suggest that iatrogenic effects of early MRI are worse disability and increased medical costs and surgery, unrelated to severity.

www.ncbi.nlm.nih.gov

-i am not talking about early MRIs in comp cases. different animal completely

Early Imaging for Back Pain in Older Adults

This prospective cohort study found that health outcomes for elderly patients with back pain were no better for those who underwent early diagnostic imaging than those who did not.

jamanetwork.com

-i am not talking about PCPs ordering MRIs for early back pain either


meta-analysis by Chou

ACP Journals

complete garbage. does not take into account what we actually do or how we do it. also, it only looked at acute or subacute LBP/ --- again, not what i am talking about



like i said before, the research on this is not good.

 

[SSdoc33]

more acute LBP in PCP setting

Application of “less is more” to low back pain - PubMed

An initiative of the National Physicians Alliance, the project titled "Promoting Good Stewardship in Clinical Practice," developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of...

www.ncbi.nlm.nih.gov

 

[SSdoc33]

this is the only think i can find specifically related to MRIs and MBBs.

the Koreans seem to like the it.

Predictors of Response to a Medial Branch Block: MRI Analysis of the Lumbar Spine - PubMed

The aim of this study was to determine the association between radiologic spinal pathology and the response to medial branches block (MBB). This retrospective observational study compared 165 patients. A successful response was defined as ≥30% or a 2-point reduction in the numeric rating scale...

www.ncbi.nlm.nih.gov

 

[deleted993114]

who among us would NOT want to see his/own MRI before a MBB? anyone? i doubt it

like i said, ill get to the literature when i have the time, but im sure to run into some meta-analysis by Chou. is that where you want to hang your hat, Hawkeye? he is basically the anti-christ on this board

Obviously, you have not "gotten to the literature", otherwise you would not think the way you do. When you do "get to the literature" (which universally shows you are completely wrong), you will choose to ignore it anyway, so what is the point?

Here is a start:

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain - PubMed

The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.

www.ncbi.nlm.nih.gov

Your "article" is garbage, of course. A 30% positive response? Where in the world is that ever considered positive?

 

[SSdoc33]

Obviously, you have not "gotten to the literature", otherwise you would not think the way you do. When you do "get to the literature" (which universally shows you are completely wrong), you will choose to ignore it anyway, so what is the point?

Here is a start:

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain - PubMed

The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.

www.ncbi.nlm.nih.gov

Your "article" is garbage, of course. A 30% positive response? Where in the world is that ever considered positive?

the best you can come up with is that MRIs cost a lot in Persia? So do their rugs.

it really comes down to what is deemed "clinically appropriate". my definition is a bit different that Roger Chou's

 

[SSdoc33]

Obviously, you have not "gotten to the literature", otherwise you would not think the way you do. When you do "get to the literature" (which universally shows you are completely wrong), you will choose to ignore it anyway, so what is the point?

Here is a start:

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain - PubMed

The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.

www.ncbi.nlm.nih.gov

Your "article" is garbage, of course. A 30% positive response? Where in the world is that ever considered positive?

i posted 4 articles, btw

 

[lobelsteve]

Would you want one before a mbb on your back?

Nope.

 

[deleted993114]

i posted 4 articles, btw

Here is the "gold standard" article which drew attention to the inappropriateness of lumbar MRIs for back pain:

You do understand that your ordering practices are being followed by CMS, don't you? You WILL eventually be required to adhere to appropriate prescribing practices, whether you like it or not. Those two standard deviations outside of the mean will be required to have EVERY MRI they order be approved or reviewed prior to authorization.

You are hurting, not helping, patients with these inappropriate imaging studies. The literature clearly shows this.




Lancet. 2009 Feb 7;373(9662):463-72. doi: 10.1016/S0140-6736(09)60172-0.
Imaging strategies for low-back pain: systematic review and meta-analysis.
Chou R1, Fu R, Carrino JA, Deyo RA.
Author information
1Oregon Health and Science University, Portland, OR, USA.
Abstract
BACKGROUND:
Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions.
METHODS:
We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model.
FINDINGS:
We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term (up to 3 months, standardised mean difference 0.19, 95% CI -0.01 to 0.39 for pain and 0.11, -0.29 to 0.50 for function, negative values favour routine imaging) or long-term (6-12 months, -0.04, -0.15 to 0.07 for pain and 0.01, -0.17 to 0.19 for function) follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings.
INTERPRETATION:
Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.
Comment in

• Imaging for low-back pain. [Lancet. 2009]
• ACP Journal Club. Review: Immediate routine lumbar-spine imaging does not improve clinical outcomes in low-back pain. [Ann Intern Med. 2009]
• Is immediate imaging important in managing low back pain? [J Athl Train. 2011]

PMID: 19200918 DOI: 10.1016/S0140-6736(09)60172-0
[Indexed for MEDLINE]

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[lonelobo]

I admit I order more MRI's than needed....unfortunately it has to do many times with patient satisfaction and expectations of referring PCP's.
They are referring to a specialists and they expect a thorough workup.
Probably not the best medicine, but the expenditures on the imaging is a drop in the bucket compared to other medical costs

 

[SSdoc33]

Here is the "gold standard" article which drew attention to the inappropriateness of lumbar MRIs for back pain:

You do understand that your ordering practices are being followed by CMS, don't you? You WILL eventually be required to adhere to appropriate prescribing practices, whether you like it or not. Those two standard deviations outside of the mean will be required to have EVERY MRI they order be approved or reviewed prior to authorization.

You are hurting, not helping, patients with these inappropriate imaging studies. The literature clearly shows this.




Lancet. 2009 Feb 7;373(9662):463-72. doi: 10.1016/S0140-6736(09)60172-0.
Imaging strategies for low-back pain: systematic review and meta-analysis.
Chou R1, Fu R, Carrino JA, Deyo RA.
Author information
1Oregon Health and Science University, Portland, OR, USA.
Abstract
BACKGROUND:
Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions.
METHODS:
We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model.
FINDINGS:
We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term (up to 3 months, standardised mean difference 0.19, 95% CI -0.01 to 0.39 for pain and 0.11, -0.29 to 0.50 for function, negative values favour routine imaging) or long-term (6-12 months, -0.04, -0.15 to 0.07 for pain and 0.01, -0.17 to 0.19 for function) follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings.
INTERPRETATION:
Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.
Comment in

• Imaging for low-back pain. [Lancet. 2009]
• ACP Journal Club. Review: Immediate routine lumbar-spine imaging does not improve clinical outcomes in low-back pain. [Ann Intern Med. 2009]
• Is immediate imaging important in managing low back pain? [J Athl Train. 2011]

PMID: 19200918 DOI: 10.1016/S0140-6736(09)60172-0
[Indexed for MEDLINE]

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look, i appreciate your point. i agree that acute to subacute axial pain without red flags should get any imaging, let alone an MRI. there is no debate on that, and the literature is clear on that point.

but that is one small slice of the clinical scenarios we face. most of the patients we see have already been though the PCP "standard care/chou" treatment algorithm.

i stated that I like an MRI before a MBB, and you took that to mean than I am somehow this massive MRI overprescriber, that I will be hunted down, and that my patients are suffering because of it. not the case at all. i order way fewer MRIs than my colleagues, and I am certainly not 2+ Std. Devs from the mean.

your article, while clear in its narrow focus, demonstrates the lack of data when it comes to MRIs and outcomes, especially in regards to chronic LBP and MBBs. the data does not exist yet. as far as "patient labeling" and increased surgical rates? these are not FMS patients or comp patients with a lifting injury. they have degenerative changes in their low back. why not call a spade a spade? and nobody fuses axial pain in my area. these are not surgical patients. the literature is totally skewed by the population that was studied (comp patients again).

 

[Ducttape]

wow it took you guys 90 posts to get to one of the main cruxes of the issue.

we are not primary care doctors, and the majority of patients we see are not acute and subacute back pain.

hawkeye, you must admit that a patient that has had several months of back pain resistant to conservative therapies such as usual care, physical therapy, median branch blocks, alternative mumbo jumbo such as chiropractic care and massage and acupuncture deserve a consideration for advanced imaging.

 

[VA Hopeful Dr]

wow it took you guys 90 posts to get to one of the main cruxes of the issue.

we are not primary care doctors, and the majority of patients we see are not acute and subacute back pain.

hawkeye, you must admit that a patient that has had several months of back pain resistant to conservative therapies such as usual care, physical therapy, median branch blocks, alternative mumbo jumbo such as chiropractic care and massage and acupuncture deserve a consideration for advanced imaging.

Also as one of those aforementioned PCPs, 90+% of my MRIs for lower back pain are because the local pain management groups won't see these patients without one.

 

[deleted993114]

Also as one of those aforementioned PCPs, 90+% of my MRIs for lower back pain are because the local pain management groups won't see these patients without one.

In the VA study, in which 39% of MRIs were found to be inappropriate, the main culprit were the experienced internists, who knew the indications for MRIs. When asked why they did it, they responded that a pain clinic or a neurosurgery clinic would not see the patient without an MRI!

So a good deal of these unnecessary MRIs are simply due to getting an "admission ticket" to a clinic. One should not demand an MRI (as in MANY instances they are not needed) and see the patient and THEN decide whether to get imaging or not.

Over ordering imaging leads to extraordinary increases in costs and leads to more unnecessary procedures and or imaging. Imaging has such been a target for quality programs and reducing costs due to physicians ordering routine inappropriate scans. Such practice not only drives up costs, but leads to WORSE healthcare, not better.

 

[deleted993114]

I admit I order more MRI's than needed....unfortunately it has to do many times with patient satisfaction and expectations of referring PCP's.
They are referring to a specialists and they expect a thorough workup.
Probably not the best medicine, but the expenditures on the imaging is a drop in the bucket compared to other medical costs

They have studied that as well. When the physician explains to the patient WHY they do not need an MRI (in contrast to what people think), patient satisfaction is not decreased. Thus, when giving talks on inappropriate imaging, one can site that study and reduce the fears of the "patient getting mad".

We are, after all, trusted with being good stewards of appropriate practice, as well as costs, and should follow what the literature states, rather than personal emotional anecdotes.

You are trained to use clinical judgement and an examination to arrive at a diagnosis. Use those skills to determine whether an image should be ordered (or not) and not just reflexively order imaging. Ordering imaging on everyone is a cop out and is poor care- such practices will soon be eliminated by fiat if practitioners do not take responsibility and help control costs.

 

[deleted993114]

wow it took you guys 90 posts to get to one of the main cruxes of the issue.

we are not primary care doctors, and the majority of patients we see are not acute and subacute back pain.

hawkeye, you must admit that a patient that has had several months of back pain resistant to conservative therapies such as usual care, physical therapy, median branch blocks, alternative mumbo jumbo such as chiropractic care and massage and acupuncture deserve a consideration for advanced imaging.

That is what the guidelines suggest. If a patient has had persistence of back pain after three months and failure of conservative care, then imaging IS indicated. Some are becoming more draconian and asking for six months of persistent back pain. I personally find little value in imaging for axial pain, in the absence of red flags, but the guidelines do allow for it with PROLONGED back pain.

Imaging IS a huge factor in increased medical expenses and is a main target for ACOs and the CMS. One way or another, further restrictions will be imposed in advanced imaging. This has come about due to irresponsible, unnecessary imaging.

JAMA: U.S. spends the most on healthcare—and imaging is a reason why


Melissa Rohman | March 14, 2018 | Practice Management

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New research, published online March 13 in the Journal of the American Medical Association, shows that the U.S. spends twice as much on healthcare as any other high-income country in the world. Heavy utilization of imaging technology was a contributing factor.
Researchers compared general spending, population health, structural capacity, utilization, pharmaceuticals, access to quality and equity in the U.S. and 10 other high-income countries, including Canada, the U.K., Germany, Japan and Sweden. Data were collected from 2013 to 2016 from international organizations such as the Organization for Economic Co-Operating and Development.
In 2016, the U.S. spent 17.8 percent of its gross domestic product (GDP) on medical spending, according to study results. In comparison, other countries spent 9.6 percent to 12.4 percent of GDP on healthcare.


Utilization in the U.S. was similar to those of other nations—except in medical imaging. The U.S. performed the second highest number of imaging exams, researchers found, and had the second highest MRI and CT technology utilization rate, following Japan. According to the study, the U.S. performed 118 MRIs per 1,000 people compared with a mean in all 11 countries of 82 per 1,000 population. The U.S. mean was 245 CTs per 1,000 population and 151 per 1,000 in other countries.
The average cost of a CT exam in the U.S. was $896 per scan as compared to $97 in Canada, $279 in the Netherlands, and $500 in Australia. Additionally, the average cost for an MRI in the U.S. was $1,145 compared with $350 in Australia and $461 in the Netherlands, the researchers wrote. Japan had the greatest number of MRI and CT scanners per one million people, at 52 and 107, respectively.
The U.S. had the second highest number of MRI units (38) and the third highest number of CT scanners (41).
"If the U.S. did less imaging and fewer of 25 common procedures, and lowered prices and the number of procedures to levels in the Netherlands, it would translate into a savings of $137 billion," wrote Ezekiel Emanuel, MD, PhD, of the Perelman School of Medicine at the University of Pennsylvania, in an accompanying editorial according to Reuters. “Regardless of what is done with the money, it would be more valuable than paying high prices for a large number of CT and MRI scans, up to a third of which may be deemed unnecessary and carry radiation risks, and many expensive but not necessary surgical procedures."


Researchers believe that targeting utilization alone is not enough to reduce U.S. healthcare spending. A more concerted effort to reduce prices and administrative costs is needed.
“There’s no doubt that administrative complexity and higher drug prices both matter, as do higher prices for pretty much everything in U.S. healthcare,” lead author Irene Papanicolas of the London School of Economics and the Harvard T.H. Chan School of Public Health in Boston told Reuters. “These inefficiencies are likely the product of a number of factors including a reliance on fee-for-service reimbursement, the administrative complexity of the U.S. health care system and the lack of price transparency across the system.”

 

[lonelobo]

clinic or a neurosurgery clinic would not see the patient without an MRI!

So a good deal of these unnecessary MRIs are simply due to getting an "admission ticket" to a clinic. One should not demand an MRI (as in MANY instances they are not needed) and see the patient and THEN decide whether to get imaging or not.

Well in an ideal world this would be right, unfortunately when a pt has to wait months to see a surgeon and potentially travel hundreds of miles to a clinic, not having an MRI causes more hardship for the patient and I would argue this does not improve care

 

[lonelobo]

They have studied that as well. When the physician explains to the patient WHY they do not need an MRI (in contrast to what people think), patient satisfaction is not decreased. Thus, when giving talks on inappropriate imaging, one can site that study and reduce the fears of the "patient getting mad".

Please share the study that shows pt satisfaction is not decreased.

 

[lonelobo]

"If the U.S. did less imaging and fewer of 25 common procedures, and lowered prices and the number of procedures to levels in the Netherlands, it would translate into a savings of $137 billion," wrote Ezekiel Emanuel, MD, PhD,

So less imaging and FEWER of 25 common Procedures.....I can't access article so no telling what 25 common procedures he is referring to ?

So lets say there $137 Billion in savings with a total healthcare spend of $3.65 Trillion works out to a 3.7% savings nothing close to the 8% we spend on administrative costs