{"id":1982,"date":"2022-03-29T18:22:58","date_gmt":"2022-03-29T18:22:58","guid":{"rendered":"https:\/\/clearhealthcareadvocacy.com\/?p=1982"},"modified":"2022-12-01T19:24:07","modified_gmt":"2022-12-01T19:24:07","slug":"cascading-care-its-quite-the-conundrum","status":"publish","type":"post","link":"https:\/\/clearhealthcareadvocacy.com\/index.php\/2022\/03\/29\/cascading-care-its-quite-the-conundrum\/","title":{"rendered":"Cascading Care: It’s Quite the Conundrum"},"content":{"rendered":"\n

I listened to an interesting podcast a couple weeks ago regarding healthcare-related \u201ccascade events.\u201d (I realize \u201cinteresting\u201d might be a stretch for those of you who, unlike me, aren\u2019t completely geeked out by all things relating to the ridiculous cost of healthcare\u2014but don\u2019t stop reading, yet.) What made this podcast really<\/em> interesting to me was that I\u2019d just been through a little cascade event of my own.<\/p>\n\n\n\n

What the heck is a cascade event?<\/strong> In generic terms, a cascade event is any event that is a direct or indirect result of a preceding event. In healthcare, cascade events have come to refer to tests, biopsies, and other procedures resulting from an initial\u2014often low-value\u2014test.<\/p>\n\n\n\n

And, what\u2019s a low-value test?<\/strong> Low-value tests\/treatments are those that tend to have very minimal clinical value. Often-cited examples are pre-operative EKGs prior to cataract surgery, chest X-rays, and antibiotics given for non-bacterial infections. Unfortunately, these low-value tests and treatments can trigger cascading events that end up hurting patients psychologically, physically, and\/or financially if they result in anxiety-producing incidental findings (think of that mysterious spot noted on a chest X-ray, which you immediately think must be cancer), more invasive procedures (when that abnormal spot on your chest X-ray least to an MRI that leads to a biopsy), and more out-of-pocket expense (MRIs and biopsies aren\u2019t free).<\/p>\n\n\n\n

One expert on the podcast I was listening to (the March 3, 2022 episode titled \u201cPain, Fear, and Waste: The Costs of Unnecessary Care\u201d<\/a> of the Tradeoffs podcast) calls these incidental findings \u201cincidentalomas\u201d\u2014abnormal findings on a low-value or not medically necessary test that lead to more testing and, ultimately, a benign result. Often, they are findings that you might\u2019ve lived the rest of your life without knowing about because they never would have caused you a problem.<\/p>\n\n\n\n

What does a cascade event look like? <\/strong>My recent cascading event started with a self-ordered heart scan\u2014you know, the $59 scans hospitals advertise on TV and billboards these days. There was no medical indication for me to have the test; I\u2019d simply heard of yet another<\/em> otherwise-healthy acquaintance about my age (47) having a heart attack, so I decided it was time to find out if the exorbitant amounts of Qdoba nachos and buttery, Kosher-salted popcorn I\u2019ve consumed over the past umpty-ump years had begun to take their toll on my arteries. And the $59 out-of-pocket expense would be totally worth the peace of mind!<\/p>\n\n\n\n

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After a week or so, when I hadn\u2019t heard anything from my PCP (who should have received the results of my heart scan, despite having no idea I was having one), I logged into my online account and found the report myself. My results? 1) A coronary artery calcium of zero (That\u2019s the best score! Here\u2019s to more nachos and popcorn!), and 2) an \u201cindeterminate density 2.3 cm lesion within the posterior right hepatic lobe.\u201d Lovely. I\u2019d gone into this heart scan expecting to find that my arteries were half-clogged with queso diablo and butter, and I came out of it with a lesion on my liver. \u201cFurther evaluation by MRI of the abdomen with intravenous contrast\u201d was recommended.<\/p>\n<\/div>\n\n\n\n

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\"\"<\/figure>\n<\/div>\n<\/div>\n\n\n\n

My mind immediately went where most patients\u2019 minds would go: either I had liver cancer, or I\u2019d finally consumed so much Pinot Grigio that my liver had begun to rot. I messaged my PCP to make sure she\u2019d seen the results. Fortunately, she nipped a lot of my anxiety in the bud by telling me they often see this on heart scans and the lesions are usually benign hemangiomas. But, she added, an MRI was definitely needed to confirm that my lesion was benign. Suddenly, my $59 heart scan had led to a much more expensive MRI\u2014and I began to write my own obituary in my head.<\/p>\n\n\n\n

It’s easy to see how\/why these cascade events get started. In a world in which patients can hop on the interwebs and immediately diagnose themselves with the worst of medical conditions\u2014and then push their doctors for whatever testing is necessary (based significantly on an emotional decision) to rule out said condition, and a world in which physicians and other healthcare professionals must constantly figure the risk of a lawsuit into their medical decision making, it\u2019s a wonder that not every diagnostic test leads to a cascade event.<\/p>\n\n\n\n

It’s also easy to see why hospitals\/other healthcare facilities offer $59 heart scans and other low-cost, low-value tests: they\u2019re banking on the fact that the findings from these tests\u2014whether related to the initial test or completely random, like mine\u2014will lead to additional tests\/procedures being performed at their facility.<\/p>\n\n\n\n

In my case, after doing a little research and finding out that I\u2019d owe over $1500 for my MRI if done at the hospital where I\u2019d had my heart scan versus owing $850 if done at the stand-alone imaging center down the street (that\u2019s about 45% less, y\u2019all), I scheduled my MRI at the stand-alone facility.<\/p>\n\n\n\n

In the end, the MRI revealed that the lesion on my liver was indeed a benign hemangioma (my very own \u201cincidentaloma\u201d!!). But this only after I experienced the psychological, physical, and financial repercussions the podcasters had mentioned: anxiety over thinking I was going to die of liver cancer\/liver rot; an IV needle in my arm and the injection of contrast into my body; and the additional $850 out-of-pocket expense.<\/p>\n\n\n\n

What\u2014if anything\u2014can be done to stop these cascading events?<\/strong> Perhaps nothing. After all, often these \u201cevents\u201d are simply part of the medical diagnosing process. And sometimes these events are blessings in disguise (how many stories have you heard of people going to the ER for one problem and finding something completely unrelated, but potentially life-threatening that might have led to a horrible outcome if not detected?). But being aware of cascade events and the likelihood of \u201cincidentalomas\u201d could<\/em> prompt us to have more open conversations with our physicians regarding the value of certain tests\u2026and then make decisions to proceed with further testing based on evidence versus emotion.<\/p>\n\n\n\n

It\u2019s highly likely that our physicians will still want to cover all their bases (whether by ordering the initial test that starts the cascade or by ordering the follow-up tests\/procedures needed to diagnose an incidental finding). After all, our doctors don\u2019t want to miss a diagnosis because a) they genuinely care about our welfare, and b) they don\u2019t want to get sued.<\/p>\n\n\n\n

It\u2019s also unlikely that, even after reading studies\/being quoted statistics regarding the value of certain tests, patients will be content with not<\/em> following up on an incidental finding; we\u2019d rather undergo a more invasive and\/or expensive procedure to find out everything is okay than walk around wondering what\u2019s going on inside our bodies and whether there\u2019s something we could be doing to stop it.  <\/p>\n\n\n\n

In conclusion, I have no conclusion.<\/strong> I\u2019d like to wrap things up in a tiny little bow and tell you I\u2019ve got the magic solution to avoiding unwanted cascade events; but, alas, I do not. I suppose the whole point of this post is to simply make you aware of cascade events and their potential impact on your health (good and bad), your emotions, and your pocketbook. Thank you for subjecting yourself to my cascading thoughts. Stay healthy, and carry on\u2026<\/p>\n","protected":false},"excerpt":{"rendered":"

What are healthcare cascade events, and what do we do about them?<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[36],"tags":[40,39,38,37],"class_list":["post-1982","post","type-post","status-publish","format-standard","hentry","category-healthcare-spending","tag-cascade-event","tag-cascade-of-care","tag-healthcare-savings","tag-healthcare-spending"],"yoast_head":"\nCascading Care: It's Quite the Conundrum - Clear Healthcare Advocacy<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/clearhealthcareadvocacy.com\/index.php\/2022\/03\/29\/cascading-care-its-quite-the-conundrum\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Cascading Care: It's Quite the Conundrum - 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