This is a continuation of the previous blog.  If you missed it, please refer back to the entry.

The Risks of Undertreatment Rise

The prime concern with undertreatment is that a diagnosis with its subsequent complications would be missed. Consider these examples:

1. Mrs. J is complaining of a headache. The emergency department physician or internist performs an exam. Nothing significant is found and Mrs. J is treated symptomatically with a mild analgesic.

She returns several days later still complaining of headache. Further testing reveals slight weakness of the right arm. Because of ACO involvement, it might be more difficult to order expensive CT scans or MRIs, causing a delay in care. Pressure by the insurance company or the ACO to minimize testing in order to keep expenses down may have caused a delay in referral to a neurologist or a delay in making the diagnosis, while medication or other intervention may have been successful in preventing further problems such as a completed stroke.

If Mrs. J does not receive a CT scan or an MRI, she could have a stroke, sue the doctor, and ask for payment for care for the rest of her life.

2. Mr. K presents for an evaluation of abdominal discomfort. Nothing specific is found but the physician has a gut feeling that something else may be occurring. Should the patient be referred to a gastroenterologist or get expensive x-rays that will increase the bill significantly or should symptomatic medications be ordered to see if the pain goes away? The ACO may recommend symptomatic medication. A rupturing aneurysm or malignancy may be missed.

3. Mr. L presents with chest pain. An expensive stress test or angiography is not ordered. Subsequently, Mr. L has a major heart attack, from which he doesn’t recover. It is recognized that this type of testing might have major complications, but this must be balanced against the risk of not testing. Doctors may face such pressure to avoid testing in order to keep costs down.

4. Mrs. M hits her head and is treated symptomatically, only to have a subdural hematoma or subarachnoid hemorrhage show up a number of hours or days later. Recognizing the cost of the exam and the radiation exposure to the patient, the CT scan was not ordered. When there is a question of getting an exam, the medical indications and potential side effects are what should govern the decision for or against the testing, not the cost.

Reasons for Undertreatment Are Not All Financial

It’s true that undertreatment may occur for reasons having nothing to do with cost. The physician may not ask the correct questions or the patient may not give the correct answers, resulting in the physician not making the diagnosis or correctly treating the problem.

One reason may be to avoid treatment risks. The patient could develop a reaction to an antibiotic ranging from a simple rash to a fatality. Ordering CT scans and other radiologic exams carries the real risk of exposure to radiation, especially in younger children. Any invasive procedure such as a biopsy or surgical procedure may have complications including death.

Or the patient may decide not to purchase expensive medications required. The wrong treatment might modify the medical condition and mask symptoms that might have made the diagnosis clear. With a headache, the patient might quickly respond to an analgesic, causing the physician to stop the evaluation because he feels the condition was cured.

The ACO may feel that there has been too much testing and expenditure and encourage a decrease in the testing. Although the “pressure” may be subtle, it should be recognized and should not affect the physician’s standard of care.

Valid Reasons for Overtreatment will be discussed in the next blog