Happy 2011, folks! It’s a new year of reformed eating, exercising, spending, and no-smoking habits. It’s a new Congress with promises or threats (depending on your view) of healthcare repeal. And with the help of U.S. Preventive Medicine, Inc., it’s a new year for Sam’s Club shoppers to reach their health goals with the “The Prevention Plan.” Or is it?
For $99 a year, Sam’s Club shoppers can access:
a personalized, step-by-step health management program designed to help people take control of their individual health. Via an online health assessment and at-home blood test [measuring cholesterol, blood glucose, and Hemoglobin A1c levels]… members can take the first steps in identifying potential individual health issues. From there, a personalized plan is created to address risks. Personal health coaching, ongoing support, a variety of tools and a plan-wide health challenge are provided through The Prevention Plan to keep members motivated to maintain a healthy lifestyle.
Although the Plan includes a 24/7 nurse line, 20 online education programs, recommended prevention screenings, and a detailed member report, it isn’t a substitute for regular health insurance… or for a primary care physician. In a CNNMoney report, U.S. Preventive Medicine CEO Christoper Fey suggested that shoppers “[t]hink of it as what a financial planner does. He takes all the information you provide, assesses the risk and gives you a plan on how to improve your financial health. The prevention plan does a similar thing, but for your health.” In the same report, a director of health policy at Families USA, a consumer advocacy group, said that she “worr[ied] about people thinking of this prevention plan as a substitute for an annual checkup at a doctor’s office.”
Participating in preventive care and services makes a lot of (dollars and) sense. Okay, a little lame joke. Seriously, though, why sit around when you can take measures to try to maintain your health and to prevent certain diseases from occurring? The Patient Protection and Affordable Care Act recognizes the benefit of preventive care and services — remember, there’s that provision concerning free access to important screenings, tests, vaccinations, and the like.
Yet I’m somewhat skeptical about the benefits of paying $99 to enroll in this Sam’s Club Plan. For starters, it sounds like the same kind of educational information and health tips can be found on other sites such as WebMD… and at no cost to the consumer/patient. Okay, well, maybe WebMD doesn’t come with a 24/7 nurse line. Yet after you take the at-home blood test, upload the results, and figure out your health summary, you’ll still need to consult a doctor to figure out whether any additional screenings are required. So take that $99 and add to it the cost of your co-pay… or whatever you might pay out-of-pocket if you don’t have insurance.
Speaking of which, be sure to check out a recent New York Times article which reminds us how (most of) everything in life is negotiable, including healthcare and prescription costs. Similarly, a NPR blog post discusses how some drug manufacturers offer coupons or subsidy cards to reduce prescription costs–but as Kate Matos mentioned the other day here at HRW, that too comes with a cost.
A startling suggestion is buried in the fine print describing proposed changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — perhaps better known as the D.S.M. 5, the book that will set the new boundary between mental disorder and normality. If this suggestion is adopted, many people who experience completely normal grief could be mislabeled as having a psychiatric problem.
Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder. . . .[This change] would give mentally healthy people the ominous-sounding diagnosis of a major depressive disorder, which in turn could make it harder for them to get a job or health insurance. . . .
Grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.
Moving from the end of life to the beginning, another commentary mentions worries that quiet and listless preschoolers may be pigeonholed as depressed:
Today a number of child psychiatrists and developmental psychologists say depression can surface in children as young as 2 or 3. . . . [But c]lassifying preschool depression as a medical disorder carries a risk of disease-mongering. “Given the influence of Big Pharma, we have to be sure that every time a child’s ice cream falls off the cone and he cries, we don’t label him depressed,” cautions Rahil Briggs, an infant-toddler psychologist at Children’s Hospital at Montefiore in New York.
Though research does not support the use of antidepressants in children this young, medication of preschoolers, often off label, is on the rise. One child psychologist told me about a conference he attended where he met frustrated drug-industry representatives. “They want to give these kids medicines, but we can’t figure out the diagnoses.” As Daniel Klein warns, “Right now the problem may be underdiagnosis, but these things can flip completely.”
Both stories foreshadow larger struggles over the meaning of “health” in risk societies where there is less margin for error or “underperformance” at work or school. Virtually any wealthy New Yorker with small children has a story about the crucial “pre-school interviewing process,” where elite schools can use an hour-long interaction with a child to decide whether or not to accept him or her as a student. On the other end of the income scale, high unemployment means that at-will employees who can’t keep up an adequate reserve of chipper and helpful “can-do” spirit are always at risk of being sacrificed in favor of some member of the reserve corps of unemployed. Business can’t survive if it’s culture is “too nice.” And hiring may end up being driven by whether an “analysis by an organizational psychologist can tell the hirer whether an applicant will have a problem with the manager or team.”
Larger social currents are feeding anxieties about these trends. Some corporate mottos appear to be “get healthy, or else:”
“We have this notion that you can gorge on hot dogs, be in a pie-eating contest, and drink every day, and society will take care of you,” says Harvard Business School Professor Michael E. Porter, who co-authored Redefining Health Care. “We can’t afford to let individuals drive up costs because they’re not willing to address their health problems.”
Hence the wellness fixation at companies as varied as IBM, Microsoft, Harrah’s Entertainment, and Scotts. Employees who voluntarily sign up for such programs often receive discounts on health-care premiums, free weight-loss and smoking-cessation programs, gratis gym memberships, counseling for emotional problems, and prizes like vacations or points that can be redeemed for gift cards.
M. Todd Henderson assures us that “corporate nannies are superior to their state analogs in some cases,” in part because “corporate policies are subjected to more instantaneous feedback from labor markets, which reduces overreaching.” As unemployment climbs and benefits end, that “feedback from labor markets” gets weaker and weaker: employees take whatever job they can find.
What’s the end result of these trends? I can’t predict, but I think Gary Shteyngart’s recent satirical novel provides one template for the workplace of the future. His protagonist, Lenny Abramov, finds that his employer has placed “five gigantic Solari schedule boards” in the office. The boards:
[D]isplayed the names of . . . employees, along with the results of our latest physicals . . . our fasting insulin and triglycerides, and, most important, our ‘mood + stress indicators,’ which were always supposed to read ‘positive/playful/ready to contribute,’ but which, with enough input from competitive co-workers, could be changed to ‘one moody betch today” or ‘not a team playa this month.’ On this particular day . . . one unfortunate Aiden M. was lowered from ‘overcoming the loss of loved one’ to ‘letting personal life interfere with job.’ (57-58)
Ultimately, moods become health problems when they seriously interfere with activities of daily living, including family, work, spirituality, and play. What Shteyngart reminds us is that the demands of work are quite flexible, and always-evolving. Without a robust societal sense of the proper claims of grief and other emotions, economic imperatives are likely to shrink them inexorably. Unlike the film Gattaca, where extant social structures somehow persist in the wake of massive changes in enhancement technology, Shteyngart’s novel describes a world where relatively small changes in self-concept, media use, and aspiration in an elite can fundamentally destabilize societal expectations.
Given the current balance of power between labor and employers, the disciplinary impact of new technology is likely to rise. As Hannah Pitkin puts it, if we are not careful, the very tools invented to reduce suffering may end up increasing it, by making authorities less tolerant of human need:
We have developed astonishing techniques of communication, persuasion, indoctrination, organization. . . . Yet these extraordinary capacities somehow have not made people happy or free or even powerful. . . . We do not direct these, our alleged powers; if anything, they direct us and determine the conditions of our lives, developing with a momentum of their own in ways we cannot foresee and that are often obviously harmful to human life and civilization
The contestation of pre-school and post-death depression concerns fundamental questions about what it means to be human. Circumstances need to be better engineered to accommodate the normal range of human experience. Otherwise a Procrustean drift will result in humans better engineered to to accommodate their circumstances. As Jaron Lanier has written, “When people are told that a computer is intelligent, they become prone to changing themselves in order to make the computer appear to work better, instead of demanding that the computer be changed to become more useful” (36). Perhaps employers without “grief leave” policies should be changed more quickly than employees in search of non-medical solace.
Benjamin Franklin famously once said, “an ounce of prevention is worth a pound of cure.” The statement has that ring of truth– especially when it comes to American healthcare. Numerous studies have shown that early detection of diseases as well as interventions for bad habits (e.g. overeating and smoking) can potentially avert thousands of deaths each year. Additionally, reported by Reuters, these preventative cares can lead to massive health care savings because preventable diseases such as heart diseases, cancer, and diabetes account for 75% of the national health care spending.
Considering the potential of prevention, just last week, the White House laid out rules requiring health insurance companies to provide many preventative medical services at no cost to the consumer. The NY Times reports,
The rules will eliminate co-payments, deductibles and other charges for blood pressure, diabetes and cholesterol tests; many cancer screenings; routine vaccinations; prenatal care; and regular wellness visits for infants and children.
The rules stipulate that no co-payments can be charged for tests and screenings recommended by the United States Preventive Services Task Force, an independent panel of scientific experts. The rules apply to new health plans that begin coverage after Sept. 23 and to existing health plans that make significant changes after that date. The administration said the requirements could increase premiums by 1.5 percent, on average.
Currently, the government reports that Americans use preventive services at about half the rate recommended by doctors and public health experts. The Obama Administration, including many experts and consumers groups, is hoping that these new changes will eventually have a huge impact and Americans will take advantage of the free preventative care.
But, how much impact would it really have?
While costs have deterred some consumers from preventive care, others have avoided doctors’ offices for other reasons. For example, people with unhealthy lifestyles avoid checkups, not because of cost, but out of fear. According to the NY Times,
Recent studies have shown that people who know they have health-endangering vices (like smoking or drinking) put off appointments because they do not want a healthy-living lecture. Others do not go because they feel doomed despite medical treatment. At the other extreme are the overly optimistic who are convinced they will get better no matter what. And then there are those who are embarrassed to discuss their symptoms, such as incontinence or impotence.
The bottom line for many people is fear: fear of bad news, fear of an uncomfortable test, fear of discussing something intimate.
And other people, namely men, do not regularly see their primary care physician because men generally tend to overestimate their health. According to a survey by the American Academy of Family Physicians:
● Almost one in five men (18%) 55 years and older have never received the recommended screening for colon cancer.
● More than half (55%) of all men surveyed have not seen their primary care physician for a physical exam within the past year.
● Four in 10 (42%) men have been diagnosed with at least one of the following chronic conditions: high blood pressure (28%), heart disease (8%), arthritis (13%), cancer (8%) or diabetes (10%).
● More than one out of four men (29%) say they wait “as long as possible” before seeking help when they feel sick or are in pain or are concerned about their health.
● Despite this, almost 8 in 10 (79%) men describe themselves as in “Excellent,” “Very Good,” or “Good” health.
The “missing” men in these statistics would seem to be among those who would benefit, arguably most, from regular checkups and screenings; unfortunately, it would seem that free preventive care will not drive these groups running to the doctor. While the new rules will undoubtedly increase the number of people receiving preventive care, it is uncertain how much impact it will actually have as some groups will continue to avoid doctors regardless of costs.
Filed under: Medical Device, Prescription Drugs, preventive care
Having previously described my diet, proclivities, and the thoroughly reasonable fear I had regarding the battery of tests I would have to undergo this week at the Cardiologist’s, I am pleased to say that I did so well that my doctor no longer thinks I will need to take Lipitor. My valves seem to all flap when they’re supposed to (echocardiogram), and the nuclear stress test showed no obstructions whatsoever. But the clincher was that the calcium scan showed zero calcium. Yes, zero.
Given the high correlation between the presence of arterial calcium and propensity for heart disease in a country where heart disease is the number one killer (about every 25 seconds an American will have a coronary event) and a major medical expense, I wrote previously how it seemed penny wise and pound foolish for health insurers to not pay for calcium deposit screening. This test can offer actionable insight years prior to the onset of ultimately costly symptoms. There is, reasonably speaking, savings of more than one kind to be had in this kind of knowledge: if one knows, one can act in accord. I paid the $318 out of pocket. Now, it seems, despite the ostensible risk factors which may have counseled otherwise, I have spared my insurer the cost of a lifetime’s worth of Lipitor. And myself the burden of a lifetime’s worth of pharmaceutical dependence.
There’s a J.D. at the end of my name, not an MD, so I do not give medical advice. But I will say that the whole battery of tests was painless, congenial, and took about 4 1/2 hours spread over two visits– which is not a lot of time to invest in dispensing with the ominous unknown. Of those one every 25 seconds in America who have a coronary event, one every minute will die. Testing will help tell you where you stand, and you never know, you just might get some peace of mind.
Rarely do medical recommendations or clinical guidelines receive such immediate and passionate attention as those released this month by the U.S. Preventive Services Task Force (USPSTF), an independent panel of doctors and scientists who make recommendations to the Department of Health & Human Services. In a striking detour from prior recommendations by the Task Force and those of the American Cancer Society (ACS) that women over 40 receive a mammogram every one to two years, the Task Force now recommends:
- “against routine screening mammography in women aged 40 to 49 years”;
- “biennial screening mammography for women aged 50 to 74 years”;
- “against teaching breast self-examination (BSE)” (emphasis added).
In a radio interview on the new guidance, Dr. Bruce Calonge, chair of the Task Force, was asked about the USPSTF recommendation against routine screening for women in their 40′s and “the possibility that some women may die as a
result of not having routine mammograms.” Calonge’s astonishing answer:
“what women really need to understand in that decade is that overall reduction in mortality, which is for all comers in that age group, only about 15%, because breast cancer is relatively rare in that age group, that benefit is really quite small…”
Although he claimed that cost analysis had no place in the Task Force’s recommendations, later, focusing on early detection generally, he repeated,
“I think one of the things that is important to say… that mammography’s benefit is only a 15% reduction in mortality.”
Kathleen Sebelius, HHS Secretary, has clarified that the federal policy on breast cancer screening has not changed, despite the Task Force’s recommendations. In response to concerns that patients who seek mammograms before the age of 50 would not be covered by health insurance, Sebelius stated that she “would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.” Despite such assurances, if past experience is a guide insurance companies will use these criteria to determine coverage.
A number of professional and advocacy groups have responded to the Task Force’s November 16 recommendation. The ACS continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. The American College of Radiology issued a frankly titled statement, “USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year” and labeled the recommendations “cost cutting.” And the American Congress of Obstetricians and Gynecologists continues to recommend a screening mammography every 1-2 years for women aged 40-49 years and every year for women 50 and over, as well as to recommend BSE.
So what would the task force’s mammography recommendations mean for patients? The changes to the recommendations extend beyond the age at which they recommend beginning mammography screening. For example, the 2002 USPSTF recommendations explained, “[t]he precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences” (emphasis added). The elimination of the term “preferences” and the focus on “patient context” and the “patient’s values regarding specific benefits and harms” indicates a move toward evidence-based medicine, whereby a patient’s inclinations and personality are taken less into consideration or play a less significant role in predicting outcomes. In a November 17 New York Times article, the author asks,
Are you the sort for whom shivering in a paper gown, enduring discomfort and waiting a week for results is so unnerving that you are thrilled for a decade-long reprieve? Or are you that woman who gets an extra breast sonogram with your gynecologist even when it is not medically indicated? Do you trust scientists or prefer your own gut?
These concerns seem more like preferences than medically-supported decision-making factors. The 2009 recommendations instruct that “the patient’s values regarding specific benefits and harms” be taken into account — but do not explain how far “patient context” be considered. The recommendations do not apply to women with “known underlying genetic mutation or a history of chest radiation.” Beyond these two exceptions, how will doctors and patients make individual decisions to start regular, biennial screening mammography? The recommendations should be appreciated for confirming — to an extent — that the decision to begin regular screening mammography is individual. The doctor and patient, in collaboration, should consider the patient’s risk tolerance, family history, and any other applicable factors. Sebelius recommends that patients “[k]eep doing what you have been doing for years — talk to your doctor about your individual history, ask questions, and make the decision that is right for you.” It is unclear how the Task Force’s recommendations could affect the decision to begin mammography in an educated and reasoned way.
The Task Force’s self-examination recommendation is also worrisome. The USPSTF states that “there is moderate or high certainty that [BSE] has no net benefit or that the harms outweigh the benefits.” However, discouraging the use of self-examination — a short, free, easy, and non-invasive process — might seem astonishing to many, particularly those who have known someone for whom a BSE has been the means by which breast cancer was first discovered. Appreciating the concern about BSE leading to higher incidences of biopsies, additional screenings, and false-positive test results, with the increasing focus on disease prevention, this recommendation seems, at best, counter-intuitive, particularly when taking into account those who are uninsured and may not pursue other methods of breast cancer screening.