The Enigma of Testing

With every proposed test there must be an evaluation of the potential benefit, but also the risk: every test has risks.

Today’s topic was inspired by a recent discussion on social media, where a well-known compliance expert, who also happened to previously work for the government, posted about a cardiac test he had that was denied by his insurance company.

The story he related is that his father had heart disease, with two heart attacks and stents, but is still alive and well at 80 – and as a result, he gets a yearly EKG at his yearly physical. One year the EKG showed an abnormality, so a nuclear stress test was ordered.

The test was thankfully normal. He also has “borderline high cholesterol.” He saw a new cardiologist this year, who looked at all the tests and recommended he get a coronary artery calcium scan. He got the test, and again, thankfully, it showed no calcium buildup in his coronary arteries. And then his insurance company denied the claim for the test.

I commented that no insurer will pay for this test, because it is not accepted as a valid screening test for coronary artery disease, even though it is a Food and Drug Administration (FDA)-approved test. In fact, most hospitals gave up submitting insurance claims years ago, and simply do the test for $50-$100 in cash. This gentleman was insistent that it should be covered, and will continue to fight the denial.

Now, granted, I do not have all the details, such as his actual lipid profile breakdown, nor his blood pressure, but let’s look closer. It is important to remember that for every test we do, we must evaluate not only the potential benefit of the test, but also the risk. That’s right: every test has risks.

One can argue that there is no risk in getting an EKG (except the pain of pulling off those little stickers). But as we saw with this patient, that yearly, nearly risk-free EKG led to a costly nuclear stress test, which involved exposure to radiation, which fortunately yielded a normal result. But what if it was abnormal, and he had an angiogram, and his arteries all looked normal, but they dissected an artery and found he needed a stent?

These risks are real. When Gilda Radner died of ovarian cancer, her husband, Gene Wilder, advocated for universal screening. But the scientists looked at the data and realized that more patients would be harmed by the cascade of tests that would result from a positive screening test than lives saved detecting cancer early, because the test is not perfect. Imagine undergoing a laparoscopy, having your bowel perforated, requiring a colostomy, and then being told that the good news was that there was no ovarian cancer?

Then there is the issue of what will be done with the results. What would the cardiologist recommend if the test was abnormal, compared to what they would recommend without having that result? In the case of a coronary artery calcium test, the significant issue at hand is the use of a cholesterol-lowering medication. Since this person may a significant family history (we don’t know at what age the father developed heart disease) and seemingly has elevated cholesterol (with no mention of LDL or HDL levels, an important factor), they might be considered at intermediate risk of developing coronary artery disease. As a result, a positive test may be viewed as another risk factor in the development of symptomatic heart disease, and the doctor may recommend a statin.

On the other hand, the patient is seemingly already at risk, and perhaps should be taking a statin regardless of the test result, in which case the test provides no additional information. And since this heart scan also has views of the other components of the thorax, there is the possibility of an incidental finding, perhaps a small lung nodule, which would then lead down the cascade of tests needed to evaluate that, along with the risks therein.

You probably have the vague sense from past articles that I am no fan of insurance companies, but in this case, I am on their side. They have done the analysis and have determined that it does not meet their coverage criteria. Just because a doctor and a patient want a test does not necessarily mean it should be covered. The science must support its use. And right now, the science is not there.

Remember, if you are going to do a test on a patient who feels perfectly fine, you better be sure you aren’t going to make things worse.

Programming Note: Listen every Monday when Dr. Ronald Hirsch makes his Monday rounds on Monitor Mondays, 10 Eastern, sponsored by R1 RCM.