Medicare Patients Often Receive Unjustified Repeat Tests

Janis C. Kelly

November 19, 2012

Medicare patients frequently receive repeats of 6 medical tests for which repetition is not routine, according to H. Gilbert Welch, MD, from the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire, and colleagues from the Medicare Payment Advisory Commission, Washington, DC.

In an article published online November 19 in the Archives of Internal Medicine, the researchers report that echocardiography, imaging stress tests, pulmonary function tests, chest computed tomography, cystoscopy, and upper endoscopy tests were repeated within 3 years in between 34.5% and 55.2% of Medicare patients tested. Moreover, metropolitan areas with high rates for initial testing are likely also to have high retest rates. According to the researchers, there were no apparent clinical explanations for the regional differences in either initial or repeat testing rates.

Routine Repetition?

The authors write, "Although we expected a certain fraction of examinations to be repeated, we were struck by the magnitude of that fraction: one-third to one-half of these tests are repeated within a 3-year period. This finding raises the question whether some physicians are routinely repeating diagnostic tests."

The authors examined patterns of repeat testing in a longitudinal study of a 5% random sample of Medicare beneficiaries. They also studied the relationship between the proportion of the population tested and the proportion of tests repeated among those tested, using the 50 largest metropolitan statistical areas as the unit of analysis.

For echocardiography, they report that more than half (55%) of those examined underwent repeat testing within 3 years and that the most common repeat testing interval was 1 year, which suggests that some Medicare beneficiaries are undergoing routine annual echocardiography. "The practice is confirmed by anecdotal observations of our cardiology colleagues, and websites indicate that such frequent testing is purported to be useful. This is despite the specific recommendation by the American College of Cardiology Foundation Appropriate Use Criteria Task Force against routine surveillance echocardiography," the authors write.

"In conclusion, diagnostic tests are frequently repeated among Medicare beneficiaries. This has important implications not only for the capacity to serve new patients and the ability to contain costs but also for the health of the population. Although the tests themselves pose little risk, repeat testing is a major risk factor for incidental detection and overdiagnosis. Our findings should foster further research in this unstudied area," the authors conclude.

Waste of Resources

In an accompanying commentary, Jerome P. Kassirer, MD, from Tufts University School of Medicine, Boston, Massachusetts, and Arnold Milstein, MD, MPH, from Stanford University School of Medicine, Palo Alto, California, write: "After decades of attention to unsustainable growth in health spending and its degradation of worker wages, employer economic vitality, state educational funding, and fiscal integrity, it is discouraging to contemplate the fresh evidence by Welch et al of our failure to curb waste of health care resources."

Dr. Kassirer and Dr. Milstein suggest that financial incentives are the main cause of unjustified repeat testing. "Many physicians privately acknowledge that financial reward is a major underpinning of these norms," they write. "When attempting to intervene, medical directors of health care systems or physicians' independent practice associations frequently face an underlying physician counterargument that they 'cannot afford' to cut back on current levels of resource use without an offsetting payment. Hippocrates and Osler would not be impressed."

Dr. Kassirer and Dr. Milstein see "real-time electronic guidance systems for physician decision making" as a way to reduce unnecessary repeat testing, along with "faster retirement of fee-for-service incentives."

The study authors and commentators have disclosed no relevant financial relationships.

Arch Intern Med. Published online November 19, 2012. Abstract