Obtaining a Correct Diagnosis Rapidly in the United States Is Associated With Many Barriers Not Present in Other Countries

Michael Laposata, MD, PhD

Disclosures

Am J Clin Pathol. 2018;149(6):458-460. 

In This Article

Abstract and Introduction

Introduction

How could the United States have such highly sophisticated medical technology and intellectual capital, spend the most money per capita on health care, but have poor health care outcomes relative to so many other countries? In a 2013 article on the US health care system published in Time magazine,[1] it was reported that in 2013, a child born in Havana, Cuba, had a better chance of living to age 2 years than a child born in the United States. Major problems in US health care infrastructure make it difficult to establish a medical diagnosis quickly and accurately.[2,3] Nine problems within the US health care infrastructure, specific to the diagnostic process, are described below.

Infrastructure Problem 1: Professional Activity in Anatomic Pathology Pays Dramatically More Than Comparable Activity in Clinical Pathology/Laboratory Medicine.

This situation has been in place in the United States for more than three decades, leading to the current circumstance in which there is only a tiny fraction of MD pathologists involved primarily or exclusively as an expert in an area of clinical pathology.[4] The consequence of that situation is that in the United States, it is extremely difficult to assemble teams of expert pathologists in the complex diagnostic areas of coagulation, endocrinology, toxicology, microbiology, and dozens of others because they simply do not exist.

In most of the world, there is no competition within pathology between anatomic pathology and laboratory medicine because they are two completely separate specialties. Individuals who enter the field of laboratory medicine are not confronted with the option of choosing anatomic pathology without gaining true expertise in clinical pathology. This is not to say that the answer is to have two separate specialties of laboratory medicine and anatomic pathology in the United States but only to make the financial incentives equal for both. This is largely an American problem.

Infrastructure Problem 2: In the United States, the Small Payment for Personalized and Expert-driven Narrative Interpretations in Clinical Pathology is Provided Only to Laboratory Directors With the MD Degree, Even if They Know Far Less Than a Non-MD Doctoral-level Laboratory Expert.

This payment disparity expectedly minimizes the interest of non-MD laboratory leaders with essential expertise in many areas. Subspecialties such as clinical toxicology are dominated primarily by PhD toxicologists. To have a system in which an MD pathologist can earn revenue by providing information that does not substantially influence the outcome of the patient, while a true expert PhD laboratory expert cannot, introduces a major problem for obtaining an accurate and rapid diagnosis. The insurers decide on who receives payment. Countries in which payment for medical care is largely from the government do not have this problem. This largely American problem can be readily fixed, if there is resolve to do so. PhD psychologists are paid for patient care activities. Why not also pay PhD laboratory directors for clinical input, which affects the treatment of patients?

Infrastructure Problem 3: There are Many More Lawsuits for Medical Errors in the United States, Creating a Defensive Position Among MD and Non-MD Doctoral Experts Who Contribute to the Diagnostic Process.

In the United States, the culture has become highly conducive to punishing knowledgeable and well-intended health care providers who, for one reason or another, reach an incorrect diagnosis.[5] The US medical malpractice industry is challenged by the use of "hired gun" witnesses, high legal fees, large malpractice premiums for health care providers, and a focus on winning the case rather than improving care. The punishment for a medical mistake, as noted by the National Academy of Medicine report on diagnostic error,[2] reduces the reporting of "near misses" and, thereby, the improvements in health care delivery that would otherwise follow. For the United States to resolve legal challenges regarding medical error without suffering an abundance of lawsuits will require a major culture change. Although this is not specifically an American problem, health care in the United States is affected by this issue much more than in most other countries.

Infrastructure Problem 4: The Competition Among Health Care Systems in the United States is Intense—even if Two Health Care Systems Fall Under the Umbrella of the Same Medical School.

A noteworthy example are the two major competing health care systems within the Harvard Medical School hospital network in Boston, Massachusetts. The competition for health care dollars limits the sharing of expertise among individuals that could enhance the accuracy and the speed of diagnosis, even when the experts are in the same city. The presence of an expert in one health care institution could entice a patient to move to a competing health care system. Importantly, no health care institution in the United States has a true expert for every condition, so sharing expertise across institutions is essential to improve the diagnostic process. This is an especially challenging problem in the United States, with its growth of financially competitive health care networks.

Infrastructure Problem 5: The Adversarial Relationship Between Administrative Leaders and Physician Leaders in Hospitals in the United States is Substantial and Becoming More Intense.

The number of hospital administrators over the past 40 years has increased by 3,000%,[6] while the number of physicians has increased 50% to 100%. In 2017, in the United States, chief executives with medical training run less than 5% of approximately 6,500 hospitals.[7] Medical practice has many unique aspects not present in other service lines. The assumption that a manager of a nonmedical enterprise is better suited to substantially improve the well-being of a health care institution by applying the same concepts from previous experience outside of medicine may be a growing misconception across the world, but it is a particularly problematic in the United States.

Infrastructure Problem 6: Nonphysician Leaders Who are Unfamiliar With the Details of the Diagnostic Process do not Understand or do not Trust Physicians Who State That Obtaining a Quick and Accurate Diagnosis Often Provides a Bigger Savings Than the Revenue Generated From a Clinical Service.

The generation of $50 of revenue is often seen as more contributory to the well-being of a health care institution than a savings of $5,000, even when the $5,000 savings is also associated with improved patient outcome and a lower likelihood of patient readmission. The intense focus on revenue over savings and patient outcome by nonmedical hospital leaders has limited the investment in valuable expert diagnostic teams who can greatly increase the financial health of hospitals in the United States by introducing substantial savings while generating modest revenue.

Infrastructure Problem 7: The Presence of the Chargemaster in Our Health Care Insurance System Provides a Major Impediment to Appropriate Payment for Valuable Diagnostic Services.

As noted in a mock exchange between a hospital administrator and a health insurance company,[8] the health insurance representative states, "I need a discount for all of my clients in your hospital because I am sending hundreds of them to you for care." The hospital executive answers, "Why don't I make a very large fake price for everything and give you a 50% discount on all of it. Too bad for those people who don't have insurance and have to pay the full amount. A small aspirin tablet could cost them $10!" The health insurance representative agrees to the arrangement because the discount sounds attractive and will likely bring more clients to the health insurance program. For this reason, the chargemaster in our health care institutions has long lost its ability to reflect appropriate payment for technical or professional services,[1] including those provided by diagnostic experts. This is an American health care problem.

Infrastructure Problem 8: The Demand to Quantify the Savings From Diagnoses That are Rendered More Accurately and More Quickly Because of Expert Diagnostic Input is Difficult at Best. However, Complex and Time-consuming Analyses are a Requirement by Many Nonphysician Leaders of Health Care Institutions With Little to no Knowledge About the Diagnostic Process Before Supporting Expert Diagnostic Teams.

For example, a patient with a deep vein thrombosis has at least six possible outcomes that range from complete dissolution of the clot with no adverse effects to the development of a lethal pulmonary embolism or a completely disabling stroke. Therefore, the cost benefit from a rapid and accurate diagnosis ranges from nearly nothing to hundreds of thousands of dollars per year, depending on the growth, dissolution, or movement of the clot. It is well known to those who practice medicine that rapid diagnosis of the blood clot has a major impact on avoiding major complications, which are far more costly than the salary of a diagnostic expert inside or outside one's own institution. Hospital leaders who do not practice medicine often demand studies requiring hundreds of hours of work and a team of statisticians to address questions with obvious answers to those with clinical experience. The answer to the question of whether it is better to have an expert involved in a complex diagnosis or just have the nearest nonexpert offer diagnostic recommendations becomes clear when an individual is left with only a nonexpert to provide care.

Infrastructure Problem 9: In the United States, Because Clinical Pathology has Traditionally Been Part of Pathology Coursework, and Teaching in Pathology for More Than Six Decades has Largely Been Anatomic Pathology, Graduates of American Medical Schools are Taught Virtually Nothing About the Correct Use of Diagnostic Tests.

In many countries, especially outside of North America, as noted above, clinical pathology is called laboratory medicine and is not part of pathology. Therefore, there is less of a choice among those designing a curriculum for medical students whether learning about the blood tests to diagnose a heart attack should be emphasized more than learning about the scar that is visible in the heart wall microscopically after a heart attack. That is not true in the United States. Currently, there is substantial modification of the medical school curriculum, but there is still a lag in the introduction of educational programs that improve diagnostic test utilization and the use of expert-driven interpretations of complex data.[9]

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