Free «Unnecessary Diagnostic Exams for Medical Insurance Purposes» Essay Sample

A diagnostic exam is a test performed on a patient; this assists in the detection of an ailment. It refers to the practice of attempting to determine or identify a certain disorder. The opinion reached by this procedure is referred to as the diagnostic opinion or the diagnostic exam result. Diagnostic exam results help in classification of the ailment in terms of treatability and severity. Diagnostic exams help the doctor determine whether an individual is free from an ailment or not.

Some medical examination procedures have higher health risks than others. Some procedures may even need some general anesthesia, such as mediastinoscopy. However, there are other examination procedures, such as pap smear and blood test, that have little to no direct risk. Some medical examinations may have indirect risk. An example of an indirect risk is that riskier test may be required after the first test has been performed. It is most certain that doctors have biases. The best way to deal with these biases is to set clinical guidelines and have them reviewed by an external body of experts.

Unnecessary Diagnostic Exams for Medical Insurance Purposes


Aim of Diagnostic Test

The main aim of a diagnostic test is to find out whether a condition is present in the target patient or not.            Diagnostic exam results should be interpreted by a professional who fully understands the imprecision and inaccuracy of gadgets used for exams. The healthcare provider should also be able to explain diagnostic test results to the patient. This will help the patient understand the cause of symptoms exhibited (Booth, 2009).

Diagnostic exams have a reference group. These reference groups are used to establish performance data, such as relative risks or likelihood ratios of a disease occurring. These reference groups may also be used to determine other performance data, such as predictive values. The performance data is then used to determine the post-test probability for a patient. When analyzing the diagnostic exam results of an individual, exam results from previous procedures may be used to interpret subsequent tests (Buck, 2011).

Interpreting Diagnostic Results

 If diagnostic test results are abnormal, the doctor should explain to the individual the grounds of symptoms and give relevant recommendations. If diagnostic exam results are normal, the healthcare provider should reassure the patient that there is no serious disease present in the body. Reassuring the patient that there is no serious ailment helps reduce the rate of successive symptoms and psychological stress. Lack of knowledge and skills by the healthcare provider about the meaning of diagnostic exam results can lead to an increase in symptoms. It may also lead to the healthcare provider’s prescribing unnecessary follow up diagnostic exams and drugs (Helen & Wyman, 2012).

A publication on October 2011 issue of British Medical Journal indicated conflicting interests of health professionals. It was evident that about half of health professionals involved in setting up clinical guidelines in Canada and the USA for cholesterol and diabetes had conflicting interests. Dr. Jonathan Gruber, an MIT healthcare economist posits that professional societies cannot be trusted in making clinical guidelines, since they make money by performing diagnostic exams on their patients. According to Dr. Jonathan Gruber, health professionals will be tempted to set up clinical guidelines that can allow unnecessary diagnostic exams to be performed on patients. He estimates that almost one-third of all healthcare spending, which amounts to about $800 billion, is used in unnecessary diagnostic exams and tests. According to Dr. Jonathan Gruber, clinical methods set by the government would help reduce the misuse of funds through unnecessary diagnostic exams (Buck, 2011).

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The American College of Physicians published guidelines to be used by all healthcare providers when dealing with patients with lower back pains. Lower back pain is a common ailment where expensive diagnostic procedure does not always help. In fact, expensive diagnostic exams end up hurting patients (Booth, 2009). According to statistical Medicare data obtained from healthcare centers, clinics and hospitals, professional doctors order MRI scans for patients with lower back pains even before trying the less expensive and safer treatments, such as physical therapy. According to research, MRI almost always leads to the expensive surgery.

According to study by the National Institutes of Health, health professional who prescribed MRI scans, which costs about $3,000, tend to prescribe expensive surgery after the MRI scans. This data was obtained from the government’s Medicare health plan for the elderly.

Spine surgeons used to treat certain back pains by fusing the back and front of two disks for decades, even though this procedure worked correctly, the operation was treated as two separate procedures. After lengthy research and discussions, surgeons concluded that fusing the front and the back of two disks “is like wearing suspenders and a belt”; they both served the same purpose. Today, clinical guidelines have been set that recommended joining either the back or the front of  disks, but not both. This means that only one procedure is required. When only one procedure is conducted, the cost of the procedure will be cut by half. There is evidence in this case that doing less is better that doing more; however, some surgeons felt that this would interfere with their decision-making. It is evident that surgeons who did not support this new guideline were only interested in making the patient pay double for the procedure (Buck, 2011).

Consequences of Unnecessary

Consequences of unnecessary diagnostics have led to law makers coming up with laws that promote lawsuits against healthcare providers, clinics and hospitals that perform unnecessary diagnostic exams. A number of states have enacted laws that forbid unnecessary diagnostic exams. For example, in the Florida Statutes, Section 766.111 which was enacted in 1985 prohibits unnecessary diagnostic exams (Helen & Wyman, 2012).

Any healthcare provider should have knowledge and skills to determine when a medical exam on a patient is not necessary. A healthcare provider may insist that such unnecessary diagnostic exams be carried out on a patient with an aim of increasing his/her profits. Such a healthcare provider should be able to justify his/her argument, failure to which the healthcare provider should be penalized (Wiley & Sons, 2004).

According to Florida Statutes, there is no medical practitioner licensed to chapter 458, 459, 460, 461 or 466 shall administer, provide, order or procure an unnecessary diagnostic exam which have not been reasonably calculated to help the medical practitioner arrive to a treatment and diagnosis of a patient’s condition. Any medical practitioner who violates this section of the law may be prosecuted and a disciplinary action taken against such a person. Any person who succeeds in a suit against a medical practitioner who has violated this section of the law shall be able to recover any attorney fee incurred (Wiley & Sons, 2004).

Practically, Medical necessity is a requirement for most services paid by private health insurers and healthcare service. The information about unnecessary diagnostic exams should be accessible by all patients to assist them in decision-making. This information is essential because it helps achieve a more educated patient populace. It helps to eliminate diagnostic exams, procedures and tests that are unnecessary and not medically necessary (Wiley & Sons, 2004).

Shannon Brownlee, the author of the book “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer", and a senior research fellow at the New America Foundation, states that patients are also to blame because they sometimes demand that doctors should do something, anything to make them feel better. This puts doctors in a dilemma; they end up performing unnecessary diagnostic exams in an attempt to make the patient feel better (Helen & Wyman, 2012).

Patients covered by insurance are easily pulled into a therapeutic tumble. The therapeutic tumble starts with screening followed by more unnecessary diagnostic tests and exams. This is then followed by unnecessary prescribed drugs and procedures (Helen & Wyman, 2012).

Most diagnostic exams and medical procedures, such as fluoroscopy, Computed Tomography and nuclear medicine imaging present a health risk to patients. These procedures have improved the treatment of numerous medical disorders; however, these tests expose patients to ionizing radiation. Ionizing radiation increases the risk of the patient’s developing cancer (Helen & Wyman, 2012).

The healthcare provider must prove that a diagnostic exam will do more good than harm to the patient. All diagnostic examinations that use ionizing radiations should only be performed when necessary and when it is proved that the diagnostic exam will help treat an ailment, or guide a procedure. Doctors must carefully consider the patient’s medical history and clinical indications before referring a patient to any diagnostic exam (Kale-Smith, 2008).


Medical practitioners should be trained on the principle used to justify whether a diagnostic exam should be conducted. Medical specialty guidelines should be set up to help the healthcare provider in making the decision on whether a particular diagnostic exam should be conducted. This will promote the ordering of only necessary diagnostic exams. Electronic health record must be available before any decision is made. This will aid in providing the physician with a history of the patient’s diagnostic examination history. The patient’s medical history will guide the physician in choosing an appropriate diagnostic exam (Kale-Smith, 2008).


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