Primum non nocere

I don’t like paying for health care that does more harm than good. It makes me mad. Yet, as a taxpayer, I’m doing just that. According to reporting by Sandra Boodman, Medicare is reimbursing providers for screenings, among other things, that should not be conducted on older patients.

First, let’s see what the evidence tells us about certain types of screening for older patients:

  • “The USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient. The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years” (US Preventative Services Task Force, October 2008).
  • “The USPSTF recommends against screening for prostate cancer in men age 75 years or older” (US Preventative Services Task Force, August 2008).
  • “The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer” (US Preventative Services Task Force, January 2003).
  • “[T]he probability of overdiagnosis and unnecessary earlier treatment increases dramatically after about age 70 or 75 years [for breast cancer]. Overdiagnosis and unnecessary earlier treatment are important potential harms from screening women in this age group” (US Preventative Services Task Force, December 2009). Note, however, evidence is insufficient to assess the benefits and harms for women after age 75.

In general, many screenings for older patients are not recommended by the USPSTF because those patients are likely to die of causes unrelated to the screening. For example, there’s little point in detecting a cancer in a 95 year old that will take a decade or more to develop. There’s certainly no point in routinely screening many 95 year olds for such cancers. And yet, as Boodman reports, Medicare is paying for many unnecessary tests done on older patients, many with a terminal illness, who are unlikely to benefit from them.

Researchers in June reported in the journal Cancer that nearly half of primary-care doctors would advise a woman with terminal lung cancer to get a routine mammogram — even if she was 80 years old. A 2010 study in the Journal of the American Medical Association of more than 87,000 Medicare patients found that a “sizeable proportion” with advanced cancers continued to be screened for other malignancies. Last May, Texas researchers reported in the Archives of Internal Medicine that 46 percent of 24,000 Medicare recipients with a previous normal test underwent a repeat colonoscopy in less than seven years and sometimes as few as three — compared with the 10 years recommended by the task force. In nearly a quarter of cases, the repeat test was performed for no discernible reason. (Medicare is supposed to cover the screening test, which can cost about $2,000, only once a decade if no cancer or polyps have been found, but the program paid for all but 2 percent of the procedures reviewed by the Texas researchers.)

Except, perhaps, by the health care providers that receive payment for such testing, who can possibly consider this good? Why is this not a tremendous waste of money and unnecessarily risky and harmful to patents (psychologically, if not physically)? What ever happened to “first do no harm” (primum non nocere)? Is it still taught in medical schools?

But, here’s the part of Boodman’s piece that really caught my attention. I don’t mean to pick on the physician she quotes, but what he said really makes me mad.

“I think we need to say we can’t do everything for everybody, and it doesn’t make sense,” said Washington radiologist Mark Klein, who recently performed a virtual colonoscopy on a 99-year-old woman. Klein said he considered not doing the procedure but decided to go ahead because he didn’t learn how old the patient was until she was lying on the table, having undergone the prep.

What kind of excuse is that? Did he explain to the patient or her family that a mistake had been made and she didn’t need the test? If he did, he didn’t say so. Did he ask the patient if she wanted the test anyway? If he did, he didn’t say so. Or did he just assume the patient wouldn’t mind the use of her time and a dose of radiation? What additional steps have been added to the “prep” so that someone remembers to check the patient’s age? Did the physician who ordered this test know the patient’s age? If not, why not?

The whole thing stinks. It’s a waste. And what we know is probably the tip of the iceberg. Are you a taxpayer? You’re paying for that iceberg.*

* However, you are not funding Medicare-reimbursed virtual colonoscopies. The program doesn’t pay for them.

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