In my last column, I wrote that the idea that increasing coverage, especially Medicaid, will lower unnecessary, high-cost emergency room care is a belief not founded in data. It will increase health-care costs while not improving care.
Another belief in the health-care act (PPACA) is that increasing easy availability of so-called preventive services with no financial obligation on the part of the patient will ultimately lower costs and improve health. The belief that “early detection” and screening for any disease saves lives or costs is unsupported. The HMO industry was founded on this belief. While there are many conditions for which such services do save lives, many don’t, and actually cause harm — and all cost a lot.
Two events have occurred in the last few years that may illustrate the problem we have.
The U.S. Preventive Services Task Force (USPSTF) evaluated the value of screening for prostate cancer with PSA tests. Their conclusion was that this test could not be recommended for all patients. They, in fact, discussed the potential harms from this test, such as impotence, incontinence, damage to pelvic structures (from radiation), unnecessary fears, etc. Their conclusion, as well as that of the major urologic organizations, was simple — discuss in detail these issues with your doctor. Evaluate for yourself the possible benefits and risks of the PSA test.
Jump ahead to the spring of 2012. Warren Buffett announces he has prostate cancer and will begin radiation therapy in the summer of 2012.
Having this test for a man his age did not meet the recommendations for his age, but as there is no “average patient” he decided to research the issue.
At a small conference for analysts, Buffett went into detail about his prostate cancer. He told the group he had evaluated the risks and the possible benefits of having a PSA at his age and made the decision to get it. When it was elevated, he consulted four urologists and decided on a further course of care.
Now on the same stage was his longtime business partner and friend (and fellow multibillionaire) Charlie Munger. He was asked about his PSA status and he told the audience that he had evaluated the test and decided not to get one. He had no interest in knowing whether he had prostate cancer.
Who was right? There is no answer. It’s an individual choice with a complex decision-making process.
There was little public discussion of the USPSTF recommendations.
Now look at the guidelines the USPSTF recommendations for breast cancer screening.
A furor occurred when they were announced, although they were consistent with data we’ve had for years. They simply summarized the observations that for a woman with no risk factors, yearly screening was not justified, and can cause unnecessary biopsies and fears.
What you’ll never hear is that if two women with no risk factors get a screening mammogram on Jan. 1, 2012, there is no basis to get another in one year. If one does find breast cancer on Jan. 1, 2013, she has no improved survival than the other who waits and finds out she had breast on Jan. 1, 2014.
Nowhere was there a push to discuss the science behind breast cancer screening of women without risk factors.
Men were considered capable of making an informed decision, while women are expected to just listen to the yearly call “it’s time for your mammogram.” “Don’t ask, just do it.”
Every organization involved in the multibillion dollar breast cancer industry pilloried the recommendations. Kathleen Sebelius, head of HHS, appeared on TV to undermine the valid science behind the work of the USPSTF (much of it done at the U of A).
The mandated benefits required by the PPACA will tremendously increase the volume of screening and “preventive” visits that have rarely been shown to benefit patients. (Screening exams are those provided to people with no evidence of a medical condition or a history that signifies increased risk of a disease. A colonoscopy for a 49-year-old man with a family history of early colon cancer is not considered a screening test because of his significantly heightened risk factor).
While it sounds nice, paying a primary care doctor to talk to a patient about the advantages of a healthy diet and exercise provides little benefits. Yet, these will be paid without any financial obligation on the part of the patient. Providing any medical service without any payment requirement on the part of the patient always leads to excess usage and abuse.
When surveyed, a majority of primary care physicians expect mandates will put a large strain on the already limited availability of primary care visits. Look at the numbers and see what will happen if every primary care doctor has to set aside several visits each week for counseling, screening and “routine” exams. Unnecessary lab tests will jump. The psychological impact of finding something that has never caused, nor will it ever, a problem for the patient is a true negative. Encouraging it is inexcusable.
Charles Barta retired to Green Valley after 10 years as a medical director for several health care insurers. Before that, he was physician-in-charge of Kaiser Permanente of Colorado and a private internist in Las Cruces, N.M. He had previously held a management position in the Medical Systems Division of Pfizer. He can be reached at Cbar52@aol.com.
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