The Cost Creep of Pap Smears

Among other things, the Affordable Care Act, and its mandatory insurance coverage provision, is supposed to slow the rising cost of health care. A story last month in the New England Journal of Medicine (NEJM) called “The Thousand-Dollar Pap Smear” is pretty clear evidence why everyone needs to pay attention to fees for services rendered.

A Pap smear is a common screening for cervical cancer that many women get annually. Generally, they are charged a relatively modest sum for their co-pay.

Pap smears are simple, fast swabs of the cervix; their widespread use over the last couple of generations significantly has reduced the incidence of a disease that once killed more American women than any other form of cancer. Most deaths from cervical cancer, according to the NEJM, occur among women who have never been screened or who have gone decades without screening.

“One of the main factors in helping to conquer this once-dreaded disease,” writes Dr. Cheryl Bettigole, “has been the availability of a cheap, effective screening test that can detect disease early, while it’s still very treatable. Yet increasingly, in my roles as the chief medical officer of a community health center and as a family doctor seeing patients in that system, I hear from women who are choosing to skip their screenings because of skyrocketing costs.”

One of her patients said she had been billed $600 for the laboratory analysis of her cervical cells. “[T]hese days,” Bettigole writes, “I am no longer surprised to find laboratory charges of $1,000 or more for a test that until recently cost only $20 or $30.”

What in the name of green cheese is going on here?

Bettigole checked it out, and found that whopping big bills list multiple charges for:

  • the Pap test itself, usually in the form of a new liquid-based test instead of an older and less expensive slide test;
  • a human papillomavirus (HPV) test, which is recommended only for women 30 to 64 years of age and only once every five years;
  • tests for sexually transmitted diseases (recommended routinely only for women 15 to 25 years of age and those with symptoms suggesting infection);
  • sophisticated laboratory tests for a variety of yeasts, the presence or absence of which was once assessed by the physician looking at a slide under a microscope.

Many patients undergoing their annual gynecology exam are unaware that the tests have been ordered or completed until they get the bill. “[S]omeone,” Bettigole explains, “whether the physician or nurse practitioner or the medical assistant processing the specimen, checked off all those boxes on the order form.”

So in too many medical practices the right hand has no idea what the left is up to.

At least Bettigole cops to it: “A mouse or a keyboard, rather than a pen, now drives the spending, but we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.”

But the labs doing the testing, she suggests, are complicit. They know that if clinicians order more tests they make more money. They’re constantly marketing “improved” tests that are easily ordered and contain several fairly esoteric tests. One such product is the single-vial women’s health test that includes Pap and HPV tests as well as tests for multiple infections that doctors would rarely have used before, and for which there’s often no evidence of benefit.

“Costly tests that once would have required physicians to submit multiple collection vials and specimens can now be ordered with the Pap smear simply by clicking a single box in the electronic medical record. Nothing at any point along the way alerts either the clinician or the patient to the high costs of these tests or to the fact that there is little medical evidence to suggest that they are useful for most patients.”

As we regularly write, all screening tests have potential risks, even if it seems like the practitioner is only covering all the possible bases. The risks of false positives, unnecessary worry and, as Bettigole points out, patients choosing not to undergo screening because of the financial consequences are considerable.

Bettigole compares laboratory marketing efforts with those employed by pharmaceutical companies, and that’s not a compliment. She makes clear that it is physicians’ responsibility to “be good stewards of limited resources and to understand the financial effects that the orders we write have on our patients.” We would add that patients as well must be aware of the potential for bill inflation.

Before you leave your doctor’s office after a pap smear, find out exactly what tests have been ordered for the sample. Let the doctor know that you are aware that unnecessary tests sometimes are piggy-backed onto the Pap test, and ask the doctor to review lab orders. Ask the doctor to note your inquiry in your chart; if the lab bill is a surprise in light of that conversation, you have substantial grounds to dispute it.

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