• 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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    • The decision to discontinue Pap smears in women over age 65 with 3 previous normals I think is questionable. Women need to be included in the discussion of discontinuing screening. The question to women needs to be if cervical or vaginal cancer were found would you treat it? At 65, most women expect to have a lifespan that would make treatment, particularly of pre-cancerous lesions or early cancer, a reasonable option. At 75, maybe not so much. Because many women are finding new sexual partners throughout their lifespans, the risk of developing cancer increases with each partner — many women don’t understand this and many MDs I know forget to ask older women about their sexual habits. Additionally, the guideline that suggests women post hysterectomy don’t need to continue Pap smears is a medical decision to not treat vaginal cancers, which we do see from time to time. I think this guideline needs to be revisited.
      Thanks.

      • Let’s strive to add more value and credibility to the discussion: Can you couch your critique in terms of published evidence? Can you indicate precisely how the USPSTF misread, misused, or ignored that evidence? This is hard work. I don’t fault you for not taking it on. But it is the way to engage in a way that is maximally convincing

        • Not directly related to above, but confusion/ambiguity in the “do no harm” realm somewhat related to below (click to stare):
          http://www.guideline.gov/search/search.aspx?term=colon+cancer+screening

          I just chose Colon Ca, but you can sub pap smears, thyroid screens, etc.

          As we implement VBI, the issue is, is USPTF last word?
          How do you resolve conflict if two professional bodies have recommendations that work at x-purposes?

          I prefer USPTF methodology, but there are instances in which their approach (if it has not been studied, no recommendation) is inadequate.

          To use your post above as example, many elder screens are egregious and unnecessary–overly so with terminal patients. However, the axiom, “chronoligic age does not equal physiologic age” complictates the lives of practitioners on a daily basis. I still struggle with how to reconcile. Age not always a correlate of near terminal states.

          Brad

    • Austin,
      Other stakeholders are responsible as well. Patients and the media, in particular.

      Witness the patient backlash, for instance, when the USPSTF changed their mammogram screening guidelines a few years back.

      I suggest reading the NEJM perspective on why cost-effective care diffuses so slowly:
      http://www.nejm.org/doi/full/10.1056/NEJMp1104675

      “Misleading headlines, designed to attract larger audiences, can make life difficult for physicians who want to practice cost-effective medicine but are beset by patients’ requests or demands for costly new therapies: the public reflexively mistrusts any apparent withholding of widely touted diagnostic or therapeutic interventions, even when they might do more harm than good.”

      Here’s my take on the issue:
      http://goo.gl/akde7

      The blame cannot be placed solely on the feet of doctors, although yes, screening 90+ year old patients for cancer doesn’t make much sense.

      Patients have to understand concepts like false positives, or the fact that screening tests can lead to more invasive studies that can potentially harm. Without patient acceptance, evidence-based practice cannot take hold.

      The media needs stop promoting the latest and greatest test.

      Doctors need a health system that gives them the time to adequately promotes informed patient choices.

      So, don’t only blame doctors, blame the system they’re forced to practice in, the patients who believe that more tests equates to better medicine, and the media that perpetuates that myth.

      Kevin Pho, MD
      KevinMD.com

      • I blogged on the Fuchs/Milstein piece: http://theincidentaleconomist.com/wordpress/in-nejm-fuchs-and-milstein-say-docs-need-to-step-up/ . But, judging from your comment, you won’t like where they and I end up. 🙂

        Anyway, though there may be plenty of blame to go around, can we at least agree that taxpayers should not be paying for tests that should not be given?

        • Yes, doctors need to take more responsibility to control costs.

          But what most progressive-leaning health policy experts tend to overlook is that patients have a shared responsibility to do so as well.

          That needs to be acknowledged, instead of placing sole blame, and responsibility, at the feet of physicians.

          Kevin

          • I don’t think acknowledgement does much. But financial incentives do. If we stop paying for Tx that are of low value, but patients want them anyway, they can pay for them out of pocket. That way, both doctor and patient have incentives for low-cost, high-value Tx. Meanwhile, taxpayers and premium payers aren’t funding the rest. Who is going to stop this policy? Both providers/manufacturers and patient advocacy groups. Who should be for it? Everyone else who pays into the system.

            If one views the largest patient advocacy group, AARP, as largely a Medigap/Medicare Advantage/Part D plan advocacy group, then the preponderance of political clout is not with patients. Therefore, though they matter, I’m not sure patients have a substantial seat at the table in the political economy of health care financing.

            Now, the shortest path to taking patient choice seriously is more consumer directed health plans (higher deductibles, higher copayments, and the like). Can patients distinguish between effective and ineffective care? The evidence says they cannot.

            The other way is for physicians and physician groups (eg the USPSTF), informed by comparative and cost effectiveness research, calling the shots on what’s worth covering and what is not. Clearly this is the heart of the debate and is not something resolvable in these comments.

    • Yes – incentives matter. Which is why no amount of bureaucratic finesse will rein in spending growth in a third-party payor model without significant cost sharing mechanisms that give both the provider and the patient and incentive to consider the how effective treatments are versus what they cost.

      I can’t help but wonder if actually keeping track of the actuarial value of Medicare contributions over time, making patients aware of their balances, and making it clear that their estates will be billed for the difference between their contributions and the aggregate cost of the care they receive would have any effect on how people (with estates) think about these things.

    • A few points: Medicare doesn’t reimburse for screening virtual colonoscopies, irrespective of age, nor do private insurers in my market (Northern Florida).
      As far as I am aware, as a practicing gastroenterologist, Medicare doesn’t reimburse for screening colonoscopies for average-risk patients any more frequently than once per decade either. The Medicare reimbursed professional fee for a screening colonoscopy is $160 and the facility fee is $450. Although hospitals may charge $2-3k to private insurers this is far above that obtained even from generous third party payers in the outpatient setting such as an ambulatory endoscopy center. That said, the overuse of these procedures is well documented, and to some extent sanctioned by Medicare. Whereas GI professional societies suggest 5 y surveillance or screening intervals for high risk individuals (personal or close family hx of colon cancer or precancerous polyps) Medicare allows for 2. This is bizarre and an invitation to the unscrupulous.

    • Sorry about the above comment’s first sentence, since it’s mentioned in the last line of the blog post (I didn’t see that when I first read it a few days ago, was it added?). In any event, the way a radiologist like Dr. Mark Klein performs in the setting of patient care is often if not usually retrospective. For most CTs the technical aspect is performed by staff and the radiologist never lays eyes on the patient. The requisition is read along with the CT, ex post facto, usually after the patient has left the premises. For certain procedures, including barium enemas, UGI series, and CT colonography, the introduction of the radiologist to the patient may take place but only after the procedure has begun; this is likely the case here. The 99 year old may have had iron deficiency signalling the significant possibility of colon cancer and his/her PMD advised a nonoinvasive alternative to colonoscopy. This is far more likely than that the 99 yo underwent the test for screening purposes since such is not paid for by medicare. You can argue the merits of attempting to diagnose colon cancer in a 99 year old with the PMD that ordered the test because he/she, not Dr. Klein, is the COST DRIVER here. If you candidly discuss their work with an honest radiologist, he/she will shake his/her head (as did Dr. Klein) at the number of repetitive, inappropriate and useless tests ordered by referring physicians in the outpatient setting, inpatient setting, and especially through the ER. The individuals ordering such tests have precious little financial incentive to do so, but do not want to take ownership of risk, even in the smallest quantities. Likewise a subspecialist receiving patients into his/her practice may order tests out of a perceived obligation to ultimately come forth with a diagnosis of exclusion when prevailing common sense would require no additional work.

      • The last line was there in the original post. Thank you for your explanation. My reaction was based on the reporting “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.” It really suggests he had a chance to stop and only did the procedure because, well, what the heck, she had been prepped.

        I’m sure you are right about how these things normally go, given your expertise. Klein and or the Boodman did not tell it as you did.