Walmart sees a bigger picture with costly imaging: frequent misdiagnosis

ctscan-300x214As Walmart tries to work with its 1 million-plus U.S. employees in controlling health care costs, the retailing giant has not only struck a blow for quality medical treatment, it also has raised key questions about a costly and booming specialization in health care: medical imaging.

Walmart decided to shake up this diagnostic field by telling its employees to pay more themselves or to first seek CT scans and MRIs at one of 800 imaging centers that a company-retained health care consulting firm has identified as providing high-quality care. Covera Health, a New York City-based health analytics company, “uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments,” Kaiser Health News Service reported.

KHN reporter Phil Galewitz said Walmart targeted improved imaging based on the giant retailers’ experiences already in funneling workers to select facilities its research has found to offer efficient, high-quality care in specific areas, such as organ transplantation, back and knee surgeries, and heart and cancer treatment.

But when Walmart patients went to the Mayo Clinic and other specialized hospitals for back operations in recent years, surgeons told them they didn’t need planned procedures because they were misdiagnosed by family or primary care doctors or needed only non-surgical treatment. The cases also pointed to high error rates in diagnostic imaging, Galewitz reported, noting this does not apply to routine X-rays or mammography.

The data on misdiagnoses due to imaging should be concerning to all patients—and to radiologists, the specialists who make the mistaken calls. They don’t typically show up in such glaring fashion, but, as KHN reported:

Studies show a 3% to 5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

In a separate story on how imaging costs led insurer Anthem to insist that the 2 million-plus patients its covers forego pricey hospital services for those offered at lower expense at independent, free-standing centers, KHN reported on another published study, cited by a health safety expert, and examining the quality of diagnoses:

[T]he perception that all imaging studies conducted by qualified providers generally yield comparable results is wrong … A study published last year in The Spine Journal, for example, found that when a patient ‘secret shopper’ with low back pain received MRIs at 10 imaging centers, each center reported different findings. Some missed a problem they should have found, while others detected nonexistent problems.

Imaging errors, experts told KHN, occur when the technicians fail to position a patient correctly in the imaging machine or because a radiologist lacks expertise or experience. Radiologists may get better at analyzing “specific types of images — like those of the brain or bones — and sometimes … they have less experience” with other cases in which they still must provide diagnoses.

But another major driver often cited, including by specialists themselves, is the volume of scans that radiologists must read and diagnose from, too often getting just seconds with each. Dr. Vijay Rao, radiology chair at the Thomas Jefferson University Hospital in Philadelphia, told Galewitz: “It’s just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen.”

What drives the frenetic pace in reading and diagnoses with scans? A study published in 2018 points the finger, as always, at profit-seeking in U.S. health care, reported the industry-targeted media organization “Health Imaging”:

The U.S. performed the second highest number of imaging exams, researchers found, and had the second highest MRI and CT technology utilization rate, following Japan. According to the study, the U.S. performed 118 MRIs per 1,000 people compared with a mean in all 11 countries of 82 per 1,000 population … The average cost of a CT exam in the U.S. was $896 per scan as compared to $97 in Canada, $279 in the Netherlands, and $500 in Australia …. The U.S. [after Japan] had the second highest number of MRI units (38) and the third highest number of CT scanners (41). “If the U.S. did less imaging and fewer of 25 common procedures, and lowered prices and the number of procedures to levels in the Netherlands, it would translate into a savings of $137 billion,” wrote Ezekiel Emanuel, MD, PhD, of the Perelman School of Medicine at the University of Pennsylvania, in an accompanying editorial … “Regardless of what is done with the money, it would be more valuable than paying high prices for a large number of CT and MRI scans, up to a third of which may be deemed unnecessary and carry radiation risks, and many expensive but not necessary surgical procedures.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become a giant ordeal for them with the soaring costs, complexity, and uncertainty of therapies and prescription medications, too many of which turn out to be dangerous drugs that cause major damages.

Patients, most of whom get their much-needed health insurance through their workplace, have found their finances strapped to the hilt these days, as companies off-load more and more medical costs onto them, especially with coverage premiums and deductibles heading ever-higher. Companies and their workers alike are seeing a developing crisis in health care costs and coverage, with individuals and families postponing and foregoing needed medical services because they can’t afford out-of-pocket costs they must pay to get past their deductibles to get health insurance benefits. This can leave them as vulnerable as if they didn’t have coverage at all.

Amazon, Berkshire Hathaway, and JP Morgan are attempting to “disrupt” health care markets and costs with a joint endeavor dubbed Haven, which hasn’t been problem free in its launch. Walmart also has taken a much-publicized leadership role in trying to cut health care costs for its workers and customers, though it, too, has hit roadblocks with its initiatives.

Still, with imaging services and misdiagnoses, the retailing giant is on to a significant health care problem. Misdiagnosis, as I’ve found in my practice, is a big issue. Diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm to patients than all other medical errors combined, experts say. Misdiagnoses boost health costs through unnecessary tests, malpractice claims, and costs of treating patients who were sicker than diagnosed or didn’t have the diagnosed condition. Experts recently noted in a health care online report that inaccurate diagnoses waste upwards of $100 billion annually in the U.S.

We’ve got a lot of work to do, and here’s hoping that corporations can be on the right side of efforts to improve health care, not just in pushing costs and problems on to those least able to handle them.

Photo credit: human brain CT scans ©Creative Commons, Department of Radiology, Uppsala University Hospital

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