"If this reading were accompanied by chest pain, you would be in the cath lab right now," the cardiac nurse educator said while analyzing the results of practice electrocardiography (ECG) being performed on me. My unconfirmed results showed nonspecific ST-segment and T-wave changes possibly consistent with anterior wall infarction. I'm a healthy, 53-year-old sports enthusiast. I was numb with disbelief.
Suddenly, I was assessing my risk. I was 20 lbs. overweight and postmenopausal, with a total cholesterol count of 204 mg/dL and a family history of early deaths from coronary artery disease; I had to admit that I was at risk for heart disease. I questioned myself at every turn: Is this pain in my shoulder related to chest pain, or did I pull a muscle raking leaves? Determined not to become a cardiac casualty, I sought my physician's advice. Until my appointment, I was irritable and distracted by worry.
According to the American Heart Association, nearly 500,000 women die of cardiovascular disease every year in the United States. Of the 435,000 who have heart attacks each year, 83,000 are under age 65, with 9,000 of those under age 45 (see AJN Reports, page 25). The typical warning signs of heart attack in women are not the same as those in men. Chest pain is number one in men; the most common prodromal symptoms in women include unusual fatigue, sleep disturbances, and shortness of breath, according to McSweeney and colleagues in the November 25, 2003, issue of Circulation. Chest pain is present in only 53% of women before a coronary event.
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My cardiologist did not take my concerns lightly, even though many physicians mistakenly overlook women's cardiac symptoms. My physician ordered echocardiography, stress ECG, and a thallium stress test. I received good news: my cardiac health was fine. My previous result was a false positive caused by breast attenuation artifact, the discovery of which restored my sense of well-being.
Unfortunately, my HMO deemed the thallium stress test "not medically necessary" because I didn't have "serious" heart problems. They said the echocardiography and the stress ECG had provided the relevant information. The additional testing exceeded the guidelines of my plan; after a two-step appeal process, the HMO covered the cost of the thallium stress test.
I've heard patients say, "I don't have to worry; my insurance is paying for this." I thought this myself when my tests were ordered. I don't use my insurance often, but if there's a problem, even just a potential one, shouldn't I expect coverage? What's the difference between legitimate diagnostic tests and needless ones that drive up costs?
My peace of mind cost my HMO $2,700. Was it worth it? You bet it was. Understanding the results of the ECG gave me a priceless sense of comfort. As I witnessed firsthand, HMOs don't want to pay for additional testing. But important information could be missed without it. I recently met a woman who suffered a heart attack at age 35. Her insurance company must now cover expensive treatments for the rest of her life. Might not early diagnostic testing have changed this predicament?
Increased insurance costs are in part the result of expensive advancements such as new drugs. Insurance companies operate within guidelines designed to curtail runaway spending, but my physician opted for the best tools available. Why should consumers and physicians be forced into a deadlock with HMOs?
This year my HMO was dropped from the list of possible providers at the hospital where I work. Costs had increased so significantly that the hospital could no longer offer it as an option; I have had to choose another. I recognize that I am a part of rising health care costs, but I can live with that. For me, further screening will be dictated by me and my cardiologist, not by an HMO.