A Matter of the Heart

Last week, the Texas House of Representatives Public Education Committee voted unanimously to pass a bill requiring students to undergo EKG screenings before participating in UIL events, The bill leaves the burden of paying for the testing up to the parents, and under our current system an EKG can cost hundreds of dollars. But how much does an EKG really “cost,” anyway? 

Adapted from my upcoming book, Your Money AND Your Life, coming Fall 2017:

“THAT one, Daddy,” said my daughter, pointing to a glossy black, ultramodern bedroom set. I didn’t agree with her choice, but it was her 12th birthday and for months, she had complained about the embarrassing roses and ribbons carved into her princess pink headboard. It was time for a change.

Now, taking my daughter shopping is a great way to do something nice for her, but what if I, as a concerned parent, want to ensure her health? Of course, she’s had all her shots and she gets a checkup every year. But as a physician, I know that there’s something that stalks our school halls, athletic fields, and playgrounds, and could threaten her life at any moment.

See, one of the biggest killers of young people every year is sudden cardiac arrest. The underlying cause is cardiac defects that occur in an estimated one out of every 500 people, making them more common than muscular dystrophy and cystic fibrosis combined. They are so prevalent in fact, that once every three days a child or adolescent becomes another statistic.

The irony is that this type of heart disease is virtually undetectable with a routine physical exam, and the majority of its victims – even those who, on the outside, look like the “picture of health” – are completely unaware that they have a ticking time bomb inside. Saddest of all, in most cases the first sign of trouble is death.

To counter this, schools have begun installing automated external defibrillators that shock the heart back to its normal rhythm. But this is too little, too late. When the heartbeat stops, it must be restored immediately. How much time do you have to save someone in cardiac arrest? Hold your breath. That’s about it.

Never was there a more pressing example of “an ounce of prevention is worth a pound of cure,” and instead of trying to hopelessly rescue its’ victims, we should be safeguarding our children against this devastating disease. Which is even more ironic – we can. Or at least, we could.

By performing a couple of non-invasive, painless, and quick tests – a 12-lead electrocardiogram (EKG) and an echocardiogram (ECHO) – we can pick up virtually all of the electric and anatomic derangements that predispose children to sudden death. Long before tragedy strikes.

But the ultimate irony is that, even though I may have input into what kind of toothpaste my daughter uses, I have zero say-so when it comes to potentially saving her life. In what amounts to a deadly Catch-22, my health insurance plan won’t authorize her to have an ECHO, or even an EKG, unless she first has symptoms of heart disease. I guess they don’t call it managed care for nothing.

So why can’t I just go and pay for these tests on my own? Well, there’s a long list of standard excuses excuses for why they shouldn’t be offered willy-nilly: the scarcity of health care resources, the notion that not all disease would be found, and the mother of them all – yep, you guessed it – the “cost.”

I actually took this line of reasoning from two reports jointly published last Fall by the American College of Cardiology (ACC) and the American Heart Association (AHA). In the first paper, the authors concluded that widespread EKG screening could not be recommended because, in addition to the other limitations listed above, the costs would amount to billions of dollars per year.

Likewise, in the second report the experts stopped well short of giving a thumbs up for ECHO’s on demand. Instead, they created a list of 113 different criteria for when an ECHO may be justified. Now, I can’t remember 113 things about college, much less keep track of the 53 “Appropriate,” 28 “May Be Appropriate,” or 32 “Rarely Appropriate” indications they created.

To me, there should only be one category, because it’s Never Appropriate to make a potentially life-saving test unavailable to someone who wants it, even if just out of curiosity.

Of course, these tests aren’t free, and if insurance won’t cover them, then who will pay for it, and how much should they be expected to pay? Considering that in our system as it stands now, an EKG can costs hundreds, and an ECHO can cost thousands of dollars, it’s no wonder mere mortals aren’t rushing out to have their children screened.

But The Big Myth of our modern American health care system, where we hear every day about the “rising costs of health care,” is that health care is – costly. When it isn’t. Or at least it doesn’t have to be.

Take for example an EKG. How much does one really cost, anyway? OK, there’s the office rent, the staff salaries, and the price of the EKG machine itself. But these are all fixed costs, which can be thought of as how much it takes to keep the doors open. And when asking how much an EKG really costs, fixed costs don’t factor in.

Because with EKG’s, hamburgers, or any other item, the fixed costs are offset by the revenue generated from each sale, and are highest in an office that isn’t performing ECGs, or ECHOs, all day. Think of it this way: when I’m not testing patients, I have a $3,000 EKG machine that doubles as a dust collector.

So the real question involves how much is the cost per test? To perform an EKG, I need ten plastic leads and a sheet of paper. Throw in a few pennies for electricity, and I can do them all day for around 50 cents a piece. The cost of an ECHO is even less: all that’s required to perform each study is about an ounce – or 20 cents worth – of ultrasound gel.

So how can something that costs less than a buck be so expensive? The reality is – it’s not. But there’s a lot of money to be made by hiding behind The Big Myth and the fear it generates, and one of the ways our health insurance/health care system maintains these artificially elevated prices is by not allowing consumerism.

If it did, then perhaps so many youngsters wouldn’t die needlessly every year. In a free market, withholding potentially life-saving technology from anyone who desires instead of “deserves” it doesn’t make any sense, even if only one life might be saved every year. Because those who wish to have an EKG, or an ECHO, or many other types of tests would be able to purchase them, at reasonable prices.

The most important point to remember is this: it isn’t the costs of health care that are outrageous; it’s the charges.

So given the failures of our flawed, self-serving, managed care system, it is time for us as a nation to put aside what used to make us comfortable, and try something new. Just like my daughter’s bedroom set, it is time for a change.

The morning after I finished writing this I celebrated at one of my favorite places. And as I dug into my $7.99 breakfast, it occurred to me that the eggs, ham, cheese, onions, mushrooms, peppers, and picante sauce that made up my omelet had cost the restaurant a lot more than the $0.75 or so it would cost me to perform both an ECHO and an EKG.

So I say to the American College of Cardiology, the American Heart Association, and everyone else who wants to continue preaching The Big Myth that health care is costly…I say eat that.

Physician. Health Insurance Agent. Author. Health care humorist. Medical satirist. Disruptor. At your service. My name is Kevin Wacasey, and I’ve been practicing medicine since 1994. When I graduated from medical school, I took an oath to do no harm to my patients. To me, that includes financial harm. But since health insurance took over health care over 40 years ago, health care prices have skyrocketed. And despite what we’re told by the media every day, it isn’t the costs of health care that are outrageous; it’s the charges. So if you’ve ever wondered why we spend so much on health insurance and health care, then come along and join me as I explore the crazy world of Healthcareonomics. Health care doesn’t have to be expensive. Let me show you how. For speaking opportunities and to pass along your questions/comments, please email me at drw@healthcareonomics.com.

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  1. You are so right, sir. I really enjoyed reading your article. I’m praying that other states follow Texas’ lead and mandate ECG’s.

  2. Genevieve

    Thank you sir. I really hope more people become aware of this. There is such a lid on society 🙁

  3. I am with Operation Screen Your Athlete based out of Lubbock, Tx. We offer free cardiac screenings for athletes ages 14-18. I loved your article and hope you don’t mind if I share it!
    Ginger Yaeger, RN
    VP and co-founder Operation Screen Your Athlete

  4. Dr. Liz

    I see that you don’t really factor in the cost of the professional fee to interpret the test. How then should doctors make a living? Maybe they too should be paid a “fixed salary” by the State. What’s lacking is the traditional, competitive free market fee for service sans the 3rd party payer which would bring down costs plus tort reform.

    • The U.S. doesn’t have a “single payer” or “fixed salary” in place for any other private industry, and health care would be a terrible place to start that experiment (witness the VA, in which I used to be a Department Chief). And I agree that a free market can and will solve most of our health care system’s problems – read some more of my blog or my books, and you’ll see how I state that over and over again.

      But in a free market the lifespan of such things as “professional fees” or other arbitrary add-ons that jack prices up, is limited. Or I should say that in a truly free market those kinds of additional charges – whether justifiable or not – probably wouldn’t last long. Which in no way means that doctors can’t make a living. But it has to be a living that accords with and responds to the whims of…the free market. Because after all, in a truly free market what are my – or your – services really worth?

      Whatever the market will bear.

      And with the high deductibles and out-of-pocket responsibilities that patients now face, they already have a free market for most of health care (office visits, labs, radiology, supplies, minor procedures). The problem is, they just don’t know it. And they certainly aren’t taking advantage of it. Yet 🙂

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