The perspective of a pulmonary consultant occasional provides an overview of medicine. Recently a patient was referred for consultation of an emergency room evaluation. The family was very concerned over the report of a very abnormal chest x-ray.  The report indicated right middle lobe collapse, interstitial infiltrates, calcified pleural plaques, and possible pneumonia.

I remembered him from previous consultations. He looked like a robust 70 year old Eastern European. He didn’t appear ill and looked about as I had remembered him. The son, who also served as the interpreter, re-expressed the concern of a serious and grave illness. Since his chart had been retired after five years of inactivity, a search of our computerized files found our previous consultations of 2001 and 2008.

As I perused my previous consultation, I read aloud my concern about his abnormal chest x-ray in 2001, how the patient had recalled that he had a similar abnormality of his middle lobe in Hungary in 1981, he had had a bronchoscopy which revealed a narrowed bronchus to the middle lobe, that biopsies were obtained and no cancer was found obstructing the middle lobe which is a common presentation of a middle lobe lung cancer. “But is the x-ray the same?” I stated that it is impossible to ascertain if they are identical without seeing the x-ray side-by-side on my viewing box, but that considering one radiologist reading the films in 2001 and a different radiologist reading the film in 2013, it would certain appear that they were describing essentially similar films.

“But dad is so much more short of breath,” he said. “Well then, why don’t we measure his pulmonary function and determine why he’s so short of breath.” I found his old PFT on my laptop and printed it out showing a mid-expiratory flow rate of 14% of normal, and then did a current PFT which showed the same flow parameter at 12% of normal. The son immediately mentioned that his dad had obviously gotten 2% worse. I pointed out that this was probably within the standard deviation of testing and was really the same value. The son breathed a sigh of relief and the patient just smiled broadly as if he never had any concern.

Looking over the 41 pages of emergency room testing, it was apparent this was well beyond the usual average of $9,000 for an emergency room visit and was more like a $20,000 relatively “non-transparent” charge. How can these costs be controlled? This has occurred over a long period of government meddling into physician work hours, giving ER evaluations greater latitude in charging Medicare, and lack of patient copayments and deductibility, all previously discussed in this column.

Since the initial complaint was chest pain, and the initial electrocardiogram was normal, a 20% copayment on a $200 ECG may have satisfied the family that he wasn’t having a heart attack. If they had stopped the testing at this point when their 20% copayment was $40, it would have save Medicare more than $20,000 in costs. If the patient had gone to the same hospital emergency room where his first 2001 tests had occurred, the initial $250 chest x-ray could have been compared to the previous one and the 50 copayment may have satisfied the family and the $20,000 in hospital costs could have been contained. If the patient would have come to the same consultant in the office that saw him in 2001, a clinical diagnosis could have been made of no change. If the family anxieties could have been relieved at that point, then the whole $20,000 cost could have been contained. Continuity of care may be the biggest restrainer of health care costs increases.

But as long as the medical illiterate control the White House, the Congress, and the AMA, reason will never prevail.

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