Stents are devices designed to hold diseased coronary arteries open to assure that blood flows through them to the heart. Since they were introduced twenty years ago, millions have been implanted. They are big money makers for the cardiologists who place them. As with any money maker, there is a temptation to place them when the situation really doesn’t call for them, when the risks to the patient outweigh the likely benefits.
Soon after stents arrived on the market, concerns arose about whether they were always being placed in patients who needed them. A number of studies were done which found that as many as 1 in 6 stents was being placed in a stable patient with no significant symptoms. These patients were not proper candidates for the procedure and it was costing the patients and the health care system hundreds of millions of unnecessary dollars as well as exposing the patients to the risk of death or serious injury. In 2009, the American College of Cardiologists, the American Heart Association and other groups published standards which identified the patients who were appropriate candidates. Stents were not to be placed in stable patients with no significant symptoms.
Recent studies have shown that since the standards were published, the rate of placement of stents in stable patients with no significant symptoms has dropped by half. While at first blush this would seem to be evidence of great progress in keeping patients safe from unnecessary procedures and in saving money for the health care system as a whole, other figures paint a different picture. At the same time that the rate of placement in stable patients with no significant symptoms was dropping by half, the number of patients described as having significant symptoms was doubling. The suspected cause for so many people being suddenly sicker was that the doctors placing the stents were describing their patients as sicker just so they could justify placing the stent. In other words, little had changed. Patients who did not need the stents were still getting them but the doctors placing the unnecessary stents were now describing their patients as sicker. The doctors have a nice name for this bit of sleight of hand. They call it “upcoding”: claiming a condition or operation is more significant than it really is to justify charging more money for it.
Upcoding to justify doing a procedure is not an innocent practice. It is unethical and is often medical malpractice. It is very difficult to identify without a close examination of the particular situation. It often places patients at greater risk and it definitely costs you and me as taxpayers and health insurance purchasers lots and lots of money. Be an informed consumer of medical services. Get a second opinion before getting a stent, unless you know your heart disease is really bad.
