Wednesday, May 4, 2011

You Pay For It--And Your Doctor May Be Making Money On It

Here we show the difference between two types of MRI. One is the industry standard, high field 1.5 Tesla MRI that has superb image quality. This is the larger image on the top. The second, middle image is from a low field 0.3 Tesla MRI that has inferior image quality. There are several technical problems with this images. This is a low field magnet that does not have optimized imaging protocols.

The bottom image, for comparison, is also a low field magnet image, but it has optimized protocols with closely followed quality assurance protocols.

None of these images has been altered except to remove confidential patient information. These are truly 'what you see is what you get' images from these different scanners.

Unfortunately, even though the image quality and, therefore, the ability to make an accurate diagnosis is impaired on a low field MR, they cost the same. Insurance companies, Medicare, Medicaid, etc, all pay the same. As a result, your copay or the amount that YOU have to pay is the same. You don't just get a discount because the image quality is suboptimal.

While this all seems unfair--and it is--what you may not know is that that low field MRI that your doctor is sending you to may be sending your doctor a check every month. For example, the image above is from a facility in Tulsa that is owned by physicians. They send their patients there not because of the image quality but, one can easily argue, because they are shareholders in the company that owns the MRI. However, I have had a physician investor at this magnet tell me that their image quality is better.

This was doctor who has no training in imaging, physics or image quality. You tell me what you think--which is clearer, more easy to see, the image on the top or the image on the bottom. Then tell me--do you think that the physician is more concerned with getting a check from his imaging center or the quality of the MRI that his patient receives? This type of unethical behavior gives the good doctors a bad name--and angers me.

There are legitimate reasons for doctors to send to certain imaging centers. Generally, hospitals do poorer quality imaging studies because they have a captive audience (at least in Tulsa). Also, I will usually send to a specific center because either I know that they perform quality imaging studies there or I am the one supervising and/or reading the imaging study.

That brings up another point. If you have an MRI, whether in a hospital or in an outpatient center, you may very well have a non-fellowship trained radiologist reading the MRI. I know this because I constantly have patients bringing in MRI reports from other facilities where the reading radiologist trained before MRI came into existence (in the 1980s) or who is just a general radiologist with no subspecialty training.

While these radiologists are board-certified, that doesn't mean that they are the best person to read your MRI. For example, who would you rather read your mother's mammogram, a fellowship-trained breast imaging specialist or me, a fellowship-trained orthopedic radiologist? When it comes to my family and my patients, I prefer for them to get the best possible treatment, and the most value for their healthcare dollar.

And no, I am not an investor at any of the imaging centers I read at.

Tuesday, April 5, 2011

Life or Death - Fixing Your Fracture

I continue to be amazed by the attitude taken by many spine surgeons regarding fixation of vertebral fractures. I can only assume that they are either uneducated or callous.

On a daily basis I hear local surgeons opine (either directly or indirectly through my patients) that vertebroplasty and kyphoplasty 'don't work', that fractures get better by themselves and that having a fracture 'won't kill you'. Although I would prefer that other doctors listen and modify their behavior, I continue to try to do the best thing for the patient. The truth is that people die of vertebral fractures--and they die for many reasons.

I can remember as an intern in internal medicine at the VA Medical Center in Oklahoma City being taught by our house officer that if a veteran came in with a vertebral fracture, that their likelihood of death was roughly equivalent to a patient being admitted for congestive heart failure or pneumonia. Yet, the next year in radiology residency, I was instructed by multiple board-certified radiologists to 'ignore those fractures' because 'they all have them.' I can't think of a more poignant contrast in knowledge and ignorance when it comes to training physicians to treat patients with osteoporotic vertebral compression fractures.

Today I would like to draw attention to yet another article showing the benefits of treating these fractures, rather than ignoring them--a recent article published in the Journal of Bone and Mineral Research (JBMR). The authors looked at death rates in 858,978 Medicare patients who were diagnosed with vertebral compression fractures. Those who underwent treatment with vertebroplasty or kyphoplasty were 37% less likely to die in the next 4 years.

There are many reasons why people die after a vertebral fracture. They often are immobilized, laid up in bed and unable to get around. They become weak and deconditioned. They develop blood clots in the legs that can travel to the heart and lungs (pulmonary embolus). They get bedsores. They get depressed and lose the will to live because of constant pain. Perhaps worst of all, fracture pain prevents them from living a normal life and stops them from doing the things that they love--the very things that make life worth living.

So, if you or a loved one suffers a vertebral fracture, this study suggests that if it is NOT treated, then you or they are 37% more likely to die in the next 4 years than if it was treated.

Yet again, more proof positive that interventional specialists who treat these fractures are on the right track. Everyday by fixing these vertebral fractures, they are not only taking away the pain, they are saving lives. Meanwhile, the doctors who continue to deny the efficacy of these procedures do so at the peril of their own patients.

Edidin A, et al. Mortality Risk for Operated and Non-Operated Vertbral Fracture Patients in the Medicare Population. JBMR, 2011: Feb 9. DOI: 10.1002/jbmr.353

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