The subtext of this post is obviously my inability to comprehend the high costs of healthcare in the USA. I am not going to add anything new to the arguments for or against defensive medicine. This debate has been raging in some corner or the other ever since the medical blogosphere came into existence.
A young college student presents to the ER with abdominal pain. She gets a CT scan. The CT scan shows an ovarian cyst. Dad, who is an MD, gets the bill for over $8,000, most of which is for the CT. Dad goes on CBS says his daughter should have had an ultrasound because it was cheaper. He says it is because the ER docs were practicing defensive medicine.
What piqued my curiosity was the sentence “Dad, who is an MD, gets the bill for over $8,000, most of which is for the CT. ”
That cannot be right, I thought. Maybe TBTAM made a mistake in the numbers. So I checked the CBS news article that she got the story from and had linked to.
Here is the pertinent extract from the news article (emphases are mine)…
It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room. There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.
But her father did - when he got the $8,500 bill, $6,500 of which was that CT scan. “I was pretty flabbergasted,” said Robert Varipapa, himself a physician. Varipapa says his daughter’s pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound. “A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.
$6,500 for an abdominal CT scan!!!
Dr. Varipapa had a right to be flabbergasted. After all, he footed the bill.
I am speechless.
Once I give you the reasons, I am sure most of you will be dumbfounded too.
They probably did a plain CT scan of the whole Abdomen on a multislice CT scanner (aka multidetector row CT / MDCT) as that is the usual emergency protocol for acute abdominal pain. This is usually adequate to diagnose appendicitis and to rule out the usual mimics of appendicitis (here is a good online article with lots of pictures).
A complete contrast CT scan (with oral or rectal contrast and intravenous contrast) would give more information, but this is unlikely to be done in an emergency.
A basic MDCT scanner (6 or 8 detector rows) costs about 2 to 2.5 crore rupees here in India (INR 20 to 25 million = US $ 500,000 to 630,000). I learnt from a source in the industry that the cost of the scanner is about 40% subsidized for the Indian market (compared to its cost in the North American & European markets). So the same basic multislice CT scanner would cost about $ 900,000 in the US.
We have a basic four-slice MDCT scanner in our hospital. A patient would be charged Rs. 3500 ($ 90, yes ninety dollars) for a plain CT scan or Rs. 4500 ($ 115) for a contrast CT scan of the whole abdomen. Ours is a small city. The charges are likely to be as high as Rs. 8000 or Rs. 9000 ($ 200 to 230) in the bigger metros like Chennai, Mumbai or Delhi.
An ultrasound scan of the whole abdomen is usually done by the radiologist (me) or another doctor who has a good deal of experience in ultrasonography. We do not have sonography technicians here in India. We have a fairly decent basic colour Doppler scanner which is more than sufficient for routine work. An abdomen scan at my department costs Rs. 350 (about $ 9 - yes nine dollars). We most often do not charge anything extra for an abdomen scan that goes on to become a transvaginal scan - as it would in case it turns out to be something like an ovarian cyst. So the lady gets two scans for the price of one.
The costs quoted in the CBS news article are ginormous. It reminds of the $456 Billion Meme that I did a few months ago.
Here’s a quick break-up…..
With the $ 6500 that was charged for one CT abdomen; I could do a contrast CT of the abdomen for fifty-six patients or a plain CT scan of the abdomen for seventy-three patients here in my radiology department in Salem.
With the $ 1400 that would have been charged for an ultrasound scan of the abdomen (if it had been done); I could do ultrasound scans of the abdomen for one hundred and fifty seven patients in my department.
Or think of it this way…
I do not understand the numbers. We pay just 40% less than the Americans for the same equipment. But we charge peanuts compared to their charges.
The argument that the quality of work is better in the US to justify the high costs would not apply to radiology. The technology and knowledge gap between radiology-as-practiced in the US and radiology-as-practiced in India isn’t all that wide.
I cannot imagine how these kind of costs can be justified.
Coming back to TBTAM’s post, there were some interesting comments. I agree completely with this one by geez…
I’m actually shocked, not living in the USA, that a ultra-sound in a hospital costs 1400$. Even given the US machine you can get for 100K, and assuming you use it on one patient a day (surely I’ve given us at least an 100x factor here), surely you’re paying the doctor or her boss at least 500$ too much for these 15 minutes. Am I missing something?
But I think the best comment was from Edwin Leap, MD, FACEP. He ends with….
Anyway, I sympathize with all parties. As a dad, I want reasonable, cost-efficient care for my children. As a doc, seeing lots of people very fast, sometimes the test that rules out the worst things fastest is the way to go. And though I’m not a surgeon, I understand that in a litigation-prone world, more information is always better than less.
It seems we want everything done, nothing missed, and all of it at a discount. Welcome to reality!
He had mentioned his “latest blog post on why that CT cost $8000, or something ridiculous like that, and what we should do with that bill.” I tried to get to his blog but the link on his name took me to a Blogger ‘profile not available’ page. Google to the rescue and I found his blog and the post in question, which was basically about his son’s appendicitis and surgery.
Thought provoking post, even for someone like me who has minimal knowledge of the way the US healthcare system works.
Now is the time for me to do some ‘holier-than-thou’ preaching.
Indians who read this, medical professionals or laypeople, should be thankful for the fact that in any reasonably good radiology setup in India, one gets scans of first-world quality at third-world prices.
Update (November 17, 2007):
Found this excellent post by Aggravated DocSurg through GruntDoc. Not pertinent to the cost of CT scans in the US, but a very good explanation of the utility (or lack thereof) of CT scan in the diagnosis of Appendicitis.