NEJM: The Thousand Dollar Pap Smear

Cheryl Bettigole, MD, MPH (NPA)

Dr. Cheryl Bettigole, a New Jersey-based family practitioner and a National Physician’s Alliance board member, has written an interesting editorial in the New England Journal of Medicine in which she states she is no longer surprised when laboratories charge her patients $1000 or more for a Pap smear.

According to Dr. Bettigole, the reason for the exorbitant charges are not the actual Pap smear itself (although she does mention the fact liquid-based preps are more expensive than conventional smears), but the tests that get added on, many of which she feels are unnecessary.

These additional tests include tests for HPV and STDs and “sophisticated laboratory tests for a variety of yeasts.”  She does allow for the fact HPV testing is recommended for women between the ages of 30 and 64 every five years and routine STD testing is recommended for women between the ages of 15 and 25 who have signs/symptoms of infection.

She admits these often unnecessary tests get ordered by “a physician or nurse practitioner or the medical assistant processing the specimen”, but goes on to say laboratories must share in the blame for this problem.  Her rationale for this is that labs have made it too easy for unnecessary tests to be ordered.

What used to require physicians to submit multiple collection vials and check multiple boxes on a requisition form now requires only one vial to be submitted and one box for a number of bundled tests to be checked.  In addition, labs provide nothing “along the way” that alerts the physician or the patient to the tests’ cost or their clinical utility.

She also mentions the “savvy” marketing tactics employed by laboratory salespeople that mirror those in the pharmaceutical industry.

In the end, Dr. Bettigole worries these excessive lab costs may lead some women to forego cervical cancer screening simply because they cannot afford it.

Commentary

I completely agree with Dr. Bettigole that it would be an absolute travesty for any woman to not be screened for cervical cancer because of the expense.

And while I certainly applaud Dr. Bettigole for writing this editorial (and the NEJM for publishing it), I do have some additional thoughts.

I agree the responsibility lies with the clinician

I can do nothing but agree with Dr. Bettigole when she says, “…we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.”

An exception to this exists in the world of surgical pathology, where additional immunohistochemistry, molecular tests, etc. may be necessary for final diagnosis, and the pathologist usually performs those sans an order from the clinician.

In my opinion, however, it matters not if a lab sends the slickest, best-dressed, and most knowledgeable and charming salesperson to the physician’s office, or if the lab uses an order form with only one box for all the tests it performs.  The only tests that should be ordered are the ones that are necessary for that particular patient.

Laboratory medicine is in many ways a service industry, and clinicians (should) understand that.  If the lab to which they send specimens regularly provides bad service by performing unnecessary or unwanted tests, or is somehow “tricking” the physician into ordering too many tests, then the physician should change labs.

That being said, there are many, many physicians out there who work for a hospital, or clinic, or some other entity that has a contract with a single lab, and they do not have a choice as to which lab they can use.

But if they do have a choice, then they are indeed responsible if a lab repeatedly provides bad patient care and they do nothing about it.

Now some of you may be wondering whether I believe it is the referring physician’s fault if a lab participates in outright fraudulent and illegal behavior (and unfortunately there are plenty of labs that do).

My answer to that is not the first time it happens, or the second, or even the third.  But if it continues to happen with such frequency that the clinician is “no longer surprised” (to use Dr. Bettigole’s words), then yes, I believe it is.

Why is a medical assistant ordering tests?

As I highlighted above, Dr. Bettigole states some of the blame for this rests on the “medical assistant processing the specimen.”  She further goes on to say (emphasis added):

It seems harmless, even possibly beneficial, to run these additional tests, and for our staff, it eliminates the risk of missing a test the doctor might have wanted to have run.

I guess I am curious as to why a medical assistant in her office is empowered to order tests she may not have even wanted.

Defensive medicine likely plays a role

Dr. Bettigole does not mention defensive medicine in her editorial, but I have to believe it is part of the problem.

It simply stands to reason that a physician’s chances of being sued decline dramatically if they don’t miss something significant.  And the way to not miss something significant is to test for it.

I see this every day around the hospital in specialties other than pathology.

For some physicians, excessive lab charges are a feature, not a bug

And now for the cynical part.

As I have discussed numerous times in the past, 31 states allow physicians to client bill for pathology services.  For those who do not know, this means referring physicians in those states can order an independent pathology lab to perform tests on samples from their patients and pay that lab (usually) far less than the usual and customary fee for those tests.  The physician can then turn around and bill the patient up to and sometimes more than the full usual and customary fee, and pocket the difference as pure profit.

So for those physicians, a $1000 bill for gynecologic tests sounds like a really good idea, because probably at least $500 of that is going straight into their pockets, all for literally doing nothing.

I want to make clear I am in no way accusing Dr. Bettigole of doing this; I am merely mentioning it as a likely motivation for many clinicians out there.

In fact, New Jersey happens to be one of the 19 states that statutorily prohibits client billing for pathology services.  So physicians there could not do this even if they wanted to.  At least not legally.

Note:  Many thanks to Ms. Naomi Kaufman Price, who alerted me to this editorial.