Monday, November 23, 2009

Healthcare: Is cost control possible?

Teenagers love to spend, Health care consumers love to test.

Recent mammogram debate shows why reform will fail - most women don't like to get mammograms later in life and less frequently. Of course, this furious reaction is fueled by those who would face payment cuts if the new guidelines are implemented - radiologists, for example.

How many medical tests do you need to sleep sound at night knowing that you are healthy enough? Billions, trillions, googols?
How many out of a few thousand existing medical tests are redundant or irrelevant to individual consumers?

Mamograms and colonoscopies are perfect examples of overused diagnostic procedures. (see also the consumerreports article on overused tests and treatments).

Colonoscopy accounts for up to 75% of costs of an IBS patient, while the probability of it yielding meaningful results is less than 3%.
Citing Dr. Rex: Low-risk patients might undergo too many colonoscopies; high-risk patients, too few. When given a range of hypothetical findings on initial colonoscopy, most physicians would recommend repeat colonoscopy earlier than is indicated by the U.S. Multi-Society Task Force guidelines.

If 2000 women are screened regularly for 10 years, one will benefit from the screening, as she will avoid dying from breast cancer.10 healthy women, however, will have either a part of their breast or the whole breast removed. Even statistics deny that early screening for breast cancer saves lives.

Early and frequent screenings often lead to false alarms and unneeded biopsies, without substantially improving women's odds of survival. About 90 percent of abnormal mammogram findings are benign. A 2009 study in the British Medical Journal estimated that roughly one in three breast cancers detected by mammograms would never have caused harm. Earlier studies were suggesting this too, raising (along with harmful consequences of false positive results)

Perhaps the biggest problem with performing too many screening tests in healthy people is a phenomenon called over-diagnosis: Screening can detect slow-growing, harmless cancers that would never have killed you. But even if a mammogram "involves a tiny dose of radiation", a bigger dose used in radiotherapy is harmful when given to healthy people. Breast cancer radiotherapy regimens can increase mortality from heart disease and lung cancer 10-20 years afterwards.

How often does this happen with breast cancer?

Dr. Kevin Pho, an internist in Nashua, N.H., thinks the rebellion indicates a larger problem with ObamaCare. "The fact that [the administration] is distancing itself from what I consider to be very robust guidelines portends a very poor future for comparative effectiveness," he says. "If they back down now, what's going to happen when a comparative effectiveness body says there's no difference between angioplasty and medical management of heart disease?"

The American College of Obstetrics and Gynecology (ACOG) has just revised their guidelines for Pap smears under some pressure. This resulted from an Annals of Internal Medicine article which documented that only 16.4% of gynecologists followed the College’s prior guidelines. Most did more screenings than indicated, the worst record of the specialties tested. But the ACOG still recommends that nearly all women obtain regular screening at intervals of 1-3 years.

Cervical cancer is a rare disease in the US: just over 11,000 cases are predicted in 2009. There will be nearly as many cases of testicular cancer, 8,400. In comparison both breast and prostate cancer are just under 200,000. Most women have been led to believe that cervical cancer is rampant and they need yearly screening to prevent it. Testicular cancer however, is rarely mentioned. Most physicians don’t even bother to recommend that young men self-examine.

Here is a different example. Man sues over “botched” testicular surgery. Doctors later discovered that the tumor was not malignant and did not need to be removed. Was it possible to offer a better testing, say biopsy? Urologists can tell you that testes should never be biopsied prior to removal if cancer is suspected as it significantly increases the risk of tumor dissemination. Studies show that those who had scrotal incisions for biopsy have a higher local recurrence rate as well as a higher relapse rate. If there is a solid growth in the testes, there is 95-97% probability of the growth being malignant. Sounds very reasonable, in this case doctors are sued for proper care, but was another cost - the cost of inconvenience, perhaps even mental trauma - ever taken into consideration?

Medicine is as much art as science – there are many cases where there are no “right” answers. Health care providers can prescribe as many procedures as they want and charge whatever they like. It's time for this to be changed.

Personal risk of cervical cancer, for example, can be easily estimated by every woman as it depends on whether she had multiple sexual partners, prior negative Paps, long term mutually monogamous relationship. HIV (that has a five times greater incidence than cervical cancer) tests are not administered to people without risks, right? Well, not quite right, but that's another story.

Dr. Joel Sherman (Medical Privacy, A Patient Oriented Discussion) has seen many women who are angry that the facts on cervical cancer have been hidden from them. They are pushed into getting Paps, but never told the pros and cons of screening. Never mentioned are the high incidence of abnormalities that resolve spontaneously, like negative biopsies and colposcopies.

And last, but not least - another reason of why healthcare is so costly - the insurer's overestimates, in a way their overdiagnosis of our health problems.

If the law says insurers have to treat every person the same, without taking into account whether they’re sick or healthy, young or old, a rational insurer will do some rational things. For example, it will assume disproportionate numbers of people who buy a policy from them will be sick and old. Of course, when they do this, the product becomes expensive, and young, healthy people start to wonder if they should even buy it in the first place. After all, they don’t really need insurance, right? Coupled with the overall rise in the cost of health care, insurers now push through new rounds of price increases, which, in turn, create more uninsured people. It is a very nasty cycle.

Aurametrix is developing decision support systems to help you evaluate personal health risks, decide on preventative measures, estimate cost/benefits of performing diagnostic tests. Better tools for a healthier world.

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