Thursday, August 30, 2007

Heart Check? Blank Cheque!

I recently came across a group of clinics called Heart Check. Clearly there is some controversy about how they operate. They advertise "free" (subject to bulk-billing conditions) heart checkups on TV and radio and encourage patients (or customers) to spread the word amongst their friends and relatives. They even advertise via Shop-a-dockets!

My patients have been telling me about their visits to these clinics. On arrival the clients fill out a questionnaire which encourages them to report the most trivial of potentially cardiac-related symptoms. An on-site GP railroads them into describing any palpitations, chest, shoulder, arm or neck discomfort, shortness of breath on (extreme) exertion, smoking history, and any personal or family history of diabetes, ischaemic heart disease, hypertension, hyperlipidaemia, obesity or any form of cardiovascular disease. There is a minimalist history or examination otherwise.

They then automatically get an ECG, and barring someone who is going to keel over and die if they walk for 2 minutes, they are then recommended to have an exercise ECG. Anyone who reports palpitations gets a Holter monitor.

Depending on the results, you are either sent to hospital, a cardiologist, a surgeon, or a GP. By depending on the results, I mean that if you are a robot whose heart rate does not vary from 60 bpm ever, you might get sent to your GP with an "All Clear" report. Otherwise, you are almost guaranteed a referral to a specialist of some sort (though if you develop an AMI on the treadmill they terminate the test and call an ambulance). Even better, sometimes they send you to your GP to get a referral to a specialist.

This is not a new idea - I suppose it all started with screening tests such as the urine dipstick for glucose (looking for diabetes) and proteinuria (for early renal failure), breast cancer and prostate cancer screening (with mammograms, breast and rectal exams and serial PSAs), and now FOB tests (for possible early bowel cancer). These are all targeted as a public service, rather than a profit-making exercise. A great deal of thought has been put into working out the pre-test probabilities for these screening tests (well, maybe not for serial PSA). Ever since then a whole series of very questionable clinics have set up shop - ranging from those offering coronary calcium scoring to whole body CT scanning. Of course Heart Check is not alone in this business (WA Cardiology offers CT Coronary Angiography).

Now, I have mixed feelings about all of this. Firstly, I have to admire Heart Check's efficiency and protocol. It is almost an ideal setup for a surgical practice. Shoehorn your patients quickly and efficiently into a provisional diagnosis, investigation protocol and treatment plan. It doesn't matter whether they really have something wrong or not - there is always someone else to palm the patients off to afterwards. Get them in and out, and make a mint along the way. My accountant would love a practice like that.

After a great deal of consideration, though, I have decided that what they do is blatantly unethical. The fact is that they prey on public fears of heart disease. Like all good advertisers, they create a need by convincing the general public that they could have a hidden risk of dropping dead - all preventable by having an ECG. Even better - it's free!

They skirt around Medicare requirements by employing an on-site GP, even though the GP has no role other than to initiate these investigations, and in fact, does not even need to hold any qualifications such as an FRACGP. They perform an abbreviated stress test (on behalf of an off-site cardiologist), and consider abnormal what most sensible doctors would see as normal findings (so that the patients feel that they "found something"). They then take no responsibility for subsequent care, and refer off to a host of other specialists via the patient's normal GP.

And then they dare to claim it all on Medicare so that our taxes foot the bill. Generally there is a gap fee for anything other than the basic 12-lead ECG, but you wouldn't know it from the advertising. When noise-complaints group Noisewatch tried to stop Heart Check's rather annoying advertisements they lost out. Perhaps they might have had more luck if they'd focused on the last line in the ad: "It's fully covered by Medicare."

But how can I complain when they introduce patients back into the health system, ultimately providing me with a source of referrals, all of whom I can safely pat on the back and say that despite what the doctor at the Heart Check clinic told them, their tests results are well within normal range, their lack of symptoms are nothing to worry about, and send them on their way with a nice fat bill (again, largely subsidised by Medicare). Sometimes I even find something real, such as a hernia, on my clinical examination which I can, in turn, investigate and treat even though the patient never complained of anything in the first place!

Have I been seduced by the referral merry-go-round? Am I getting sucked into the unnecessary investigation whirlpool? Perhaps it is normal practice in somewhere like the US - but it seems decidedly out of place in Australia.

1 comment:

Michael said...

Look, there is no question here. It is unethical practice. It is health profiteering and on the public purse. If people want to get unnecessary tests and are willing to pay for it, then they can go right ahead but this disgraceful.

What I do is that I strongly dissuade people from attending these sort of clinics. To me, rubbery ethical standards = rubbery clinical competence.

Michael Tam