Throwing the baby out with the bath water

But that just means that both doctors and patients have to use judgment — indeed, both groups need to be taught how to use better judgment — in utilizing the results of tests, not that doctors should endeavor to minimize the information they have available to assess a patient’s condition.

Another conflation is between different types of tests. It seems misguided from a quality care point of view to treat non-invasive or low-risk testing (like blood testing, ultrasound scans, or colonoscopies) in the same way that one would evaluate testing that carries greater risk.

Lurking in Rosenthal’s analysis, like that of virtually everyone thinking about the provision of health care, are cost concerns. She cited a researcher that “has estimated that unneeded blood tests during physical exams alone cost $325 million annually.” Assuming that number were true, it needs to be put in context. First, one should note that it’s about $1 per American (or, perhaps, $2 if we assumed that twice as many Americans could be getting such testing than are actually doing so).

In any event, these costs are tiny when compared either to overall health expenditures or to the dollars paid for private health insurance that don’t go to patient care.

According to data from the National Health Statistics Group of the Centers for Medicare and Medicaid Services, published earlier this year, overall health expenditures in the U.S. in 2010 totaled almost $2.6 trillion, and the “net cost” for private insurance (the amount in premiums not paid out for medical services) was $102 billion, more than 300 times the cost of the blood testing characterized as unnecessary.

A genuine conversation about quality health care would not exclude the substantive concerns that Rosenthal raised, but would consider alternatives to simply doing without, and would be prepared to discuss various kinds of testing that are underutilized (as, for example, transvaginal ultrasound, a relatively inexpensive procedure, generally entirely without risk, that can detect more readily than customary gynecological exams the presence of ovarian cancer or other pelvic abnormalities).

We’re not going to being able to have that conversation unless we’re able to put to the side — at least for a few minutes — the question of cost, and make sure to begin and end with what is best for patients.

Then we can discuss whether we’re a society that is prepared to pay for what is needed.