New Breast Cancer Screening Recommendations Cause Controversy

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.

Urgency, Medicalization, and Sick Days

The US media have recently coalesced around a narrative asserting that US health care costs too much in the aggregate because citizens are demanding too much health care. But the “too much demand” narrative must be balanced by an awareness of high prices in the US, as Ezra Klein has pointed out on the provider side, and Uwe Reinhardt notes on the insurer side. Reinhardt cited a study that found that, in comparison with West Germany, “in 1990 Americans received $390 per capita less in actual health care but spent $360 more per capita on administration.”

Nevertheless, there are legitimate concerns that citizens of the developed world are demanding (or having foist upon them) “too much health care,” as Charles J. Wright argues in the Literary Review of Canada. For example, Wright observes that

The recent analysis of all the available evidence from multiple studies published in the British Medical Journal shows that if 2,000 women are screened with mammograms regularly for ten years, only one single woman’s life will be prolonged, but 500 will have at least one false positive and ten will be diagnosed with a “cancer” that would never have become a real disease if it had been left alone. . . . The diagnosis and treatment of non-disease is also popular in some areas of psychiatric practice. Among the hundreds of diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (known as the psychiatric bible) published by the American Psychiatric Association, dozens would be considered by most people as normal variants of the human condition but for the relentless attempts by the pharmaceutical industry to have them known as common diseases treatable by drugs.

Wright examines many causes for overmedicalization, but I think he misses one very important one–health concerns as a trump card over other social needs. In the US particularly, shrinking middle class incomes, weak unions, and high unemployment make it extremely difficult for the average worker to demand much in the way of vacation time, and there is virtually no political movement to guarantee such time. But there is momentum on both the federal and the municipal level to get sick days, in part because of the public health consequences of “presenteeism“–sick workers who spread flu and other disease when economic necessity forces them to go to work. While laissez-faire business interests can smear virtually any other pro-worker law as an intolerable burden on business, it is intuitively obvious why stopping the spread of disease is in everyone’s best interest.

Whatever happens as a result of this year’s health reform debate, I believe it has done some crucial normative work. After a long campaign by advocates of “consumer-directed health care” to reframe health care as just another commodity, the reform debate has focused the nation on its uniqueness, and on the moral imperative of providing some baseline of care to all. By vigorously blocking so many other modes of achieving better work conditions, entities like the Chamber of Commerce and Club for Growth have, ironically, shifted progressives’ focus to conservatives’ bete noir, the health care system. I predict that, if other guarantees of humane working and living conditions decline, we will see ever more “medicalization” as a way of upping the urgency of demands made by an increasingly pressed middle class.

Cut money to the EPA, and the US’s toxic waterways grow, increasing the flow of carcinogens to the populace. Put workers in insecure and demoralizing environments, and don’t be surprised if there’s an upsurge in demand for anti-anxiety drugs. Decimate funds for roads and public transit, and turn a blind eye to dangerous driving, and watch the ER’s fill with accident victims. The closer we come to a “minimal state,” the more we’ll see the resulting externalities increase demand for health care. The mechanic in the old oil filter commercial speaks for the public at large: “Pay me now, or pay me later.” When we defer maintenance of the social determinants of health, we shouldn’t be surprised when demand for doctors and hospitals rises.

Soda & Diabetes, How Much Does That Can of Soda Really Cost? Part II

Diabetes. In a brief but interesting interview on NPR’s Marketplace, Kaiser Permanente CEO George Halvorson had this to say:

HALVORSEN: …. Right now, when you look at diabetes, 32 percent of the cost of Medicare is diabetes. It’s the number one cost of blindness, it’s the number one cause of amputations, it’s the number one cause of kidney failures. And when you look at the care delivery patterns in America, we only get care right for diabetics 8 percent of the time. If we got care right for diabetics 80 percent of the time, we’d cut the number of kidney failures in half.

A few days ago we began to ask, “How Much Does that Can of Soda Really Cost?” We considered cost in terms of external or social cost (not price for the actual can of soda, but that which results incidental to the primary transaction and may be borne by other than the buyer or seller), and noted that a recent study shows that obesity plays a prominent role in health care expenditures, and that many believe that soda and other sugary soft drinks play a prominent role in obesity. We noted that the Wall St. Journal reported that

Overall obesity-related health spending reaches $147 billion, double what it was nearly a decade ago, says the study published Monday by the journal Health Affairs.

Obesity-related conditions now account for 9.1% of all medical spending, up from 6.5% in 1998, the study concluded.

Obesity is a key factor in Type 2 diabetes. And  32% of Medicare costs are attributable to diabetes. It is no stretch to say that if we have a Medicare cost problem in this country (we do), what we really have is a diabetes problem (and, considering Halvorsen’s “we only get it right 8% of the time” figure, a diabetes treatment problem as well).

But first things first. 32% is a mere scooch (yes, that’s the technical term) away from ONE THIRD. That’s an enormous number. If one were to relate this portion of Medicare expense to houesehold expenditures, it occupies a place similar to a mortgage– but an expensive mortgage in a house that no one wants to live in.

In addition, according to the American Diabetes Association (ADA)

The total annual economic cost of diabetes in 2007 was estimated to be $174 billion.  Medical expenditures totaled $116 billion and were comprised of $27 billion for diabetes care, $58 billion for chronic diabetes-related complications, and $31 billion for excess general medical costs. Indirect costs resulting from increased absenteeism, reduced productivity, disease-related unemployment disability, and loss of productive capacity due to early mortality totaled $58 billion.  This is an increase of $42 billion since 2002. This 32% increase means the dollar amount has risen over $8 billion more each year.

Importantly, the ADA believes those numbers may be understated:

The actual national burden of diabetes likely exceeds the $174 billion estimate because it omits the social cost of intangibles such as pain and suffering, care provided by non-paid caregivers, excess medical costs associated with undiagnosed diabetes, and diabetes-attributed costs for health care expenditures categories not studied.

Read more

Employees, Fearing Increased Cost-Sharing and Loss of Benefits, Utilize Current Employer-Based Health Plans More

The Kaiser Family Foundation reports that a recent survey reveals that employees are utilizing employer-based health plans more in fear that their plans will increase cost-sharing or dissolve altogether.

KFF reports:

U.S. workers are making more use of their employer-sponsored health insurance benefits because of concerns that employers could cut benefits or increase costs during the economic recession, according to a survey released Friday by the International Foundation of Employee Benefit Plans, the Milwaukee Journal Sentinel’s “Dollars & Sense” blog reports. IFEBP surveyed its members between March 30 and April 6 and found that one-third reported an increase in their workers filling prescription medications or undergoing costly medical procedures before their insurance runs out, the study found. Sally Natchek, senior director of research for IFEBP, said, “Plan participants are feeling anxious about the possibility of increased cost-sharing and a reduction in benefits due to the financial crisis.”

The International Foundation reports that:

[W]hile few plan sponsors (3.6%) are cutting or considering cutting health care benefits altogether, many are ramping up their cost-sharing approaches.  Thirty-five percent of plan sponsors are increasing employee deductibles, coinsurance or copays due to the financial crisis.  Nearly the same proportion are also increasing employee premiums.  Other cost-sharing actions that plan sponsors are taking include adding consumer-driven health plans as an option (12.8%), replacing a current plan with a consumer-driven plan (9.6%) and instituting spousal charges (10.8%).

The Foundation report confirms that more employers are using consumer-directed health plans in an attempt to rein in the cost of health benefits.

Perhaps the silver lining of this survey, though, is that there was also found to be “a heightened focus on wellness programs.  Eighteen percent of the respondents have introduced or are considering introducing wellness initiatives due to the economy (Foundation).” In a recent post, we noted that Kaiser had reported that

Eighty percent of large U.S. companies this year are offering chronic disease management programs for workers in an effort to reduce health care costs, up from 51% last year, according to a new survey by Hewitt Associates, the Houston Chronicle reports.

At the confluence of unfavorable economic conditions, rising health care and insurance costs and an administration which has vowed reform, these burgeoning trends may be only the forward guard in changes to employer-based plans. Driven by economic concerns, there seems to have been generated among employers an understanding that one way of avoiding the high costs associated with acute and/or catastrophic health care, is simply to help employees to avoid becoming sick (it may be only a matter of time before employers begin handing out “an apple a day.”) Unfortunately, with increasing frequency employers also seem to be learning that another means of avoiding the costs of  health care is to simply discontinue,  decrease, or “shift” the costs of health benefits. The numbers seem to suggest that employees have read the writing on the wall, and are visiting their doctors while they still can.

Free Healthcare for the Newly Uninsured?

In a move that has garnered both praise and criticism, Walgreens is offering free health care at its in-store Take Care clinics to patients (and their uninsured children and spouses) who have lost their jobs.  This program, called the Take Care Clinic Take Care Recovery Plan, is designed to assist current and future patients who lose their jobs and health coverage on or after March 31, 2009.

Free services do not include full spectrum preventive care, but do include routine screening and treatment for respiratory illnesses, seasonal allergies, urinary tract infections, etc.  Quest Diagnostics has teamed up with Walgreens to provide free laboratory testing services associated with the care of qualified patients.   A significant item not covered by the program is the cost of any prescription necessary to complete treatment for any of these conditions.

Walgreens warns that “[t]he Take Care Recovery Plan is in no way intended as a substitute to COBRA health benefits or any other insurance” and advises patients to carefully consider all forms of coverage that may be available to them given the limitations of care available for free through a Take Care Clinic.

While many may view the program as an advertising stunt, it is hard not to take solace in the fact that families who might otherwise have to resort to a hospital emergency room, and potentially face an exhorbitantly high bill, may now take refuge in a local clinic.

As the economy continues to sour and the unemployment rate reaches levels not seen in more than a quarter-century (8.5%), the impact on access to healthcare and our economy could prove to be unprecedented.  One study indicates that for every 1% increase in unemployment, Medicaid and SCHIP enrollment would increase “by 1 million (600,000 children and 400,000 non-elderly adults) and cause the number of uninsured to grow by 1.1 million.” And as we noted in a post at the beginning of this year, there are those (including Jane Sarasohn Kahn of The Health Care Blog) who believe that even that dire metric will prove to be  somewhat understated for present conditions.

I am certain that Walgreens is concerned with its bottom-line in this effort: calling it an “experiment,” restricting the hours that non-paying patients can seek care, and noting that every patient who visits a clinic talks to about 8 other people about the experience.  Most people, I am certain, are aware that the move is a mere band-aid on a wound that is hemorrhaging.  But for the families the program helps, these points are probably irrelevant.  What is relevant is the fact that a company is using its own resources to provide free health care to a growing population who need it.

Universal Health Insurance for America’s Children - Can It Happen?

It is no secret that America’s health care infrastructure leaves much to be desired.  It spends more on health care than any other country in the world, but is far from achieving the best results.  The extreme cost of care has contributed to increased rates of the un- and underinsured — climbing from 41.2 and 15.6 million in 2003 to  49.6 and 25.2 million, respectively, in 2007.

Most observers agree that the American health care system is badly broken–if it ever was intact–as evidenced by the large number of Americans without health insurance, the high and rising costs of health care, and the relatively poor health outcomes achieved for the money spent.

What might be lesser known is the degree to which lack of health coverage affects children.  In their article, Universal Health Insurance for Children, published in the Journal of Health Care for the Poor and Underserved, Hughes et al. note that despite programs designed to enhance children’s access to coverage like State Children’s Health Insurance Program (SCHIP), about 8.1 million children were a part of the uninsured population in 2007.  Confusion about eligibility is often cited as a reason many children — over 80% of low income uninsured children - who are eligible for coverage do not have it.

Children’s health insurance status helps predict whether they receive needed health care and provides a critical means for identifying and addressing their health problems early in life… Children  who experience unmet health problems are more likely to miss school, to incur high costs for medical care, and to have parents miss work due to caring for an ill child.

Consequences of non-coverage of children start with compromised access to health care and turn into compromises to the American economy.

Lack of insurance coverage for children not only has an immediate impact on those whose access to care is limited, but it also has social implications in terms of potential public health threats due to untreated communicable diseases, higher health care costs for end-stage treatment, and consequences for the economy in terms of productivity and high insurance costs to businesses.

It has been well documented that providing health insurance coverage is cheaper than paying for the consequences associated with the alternative, but America has been resistant to providing universal coverage.  Providing coverage specifically for children, on the other hand, has been met with less resistance.

The social and individual benefit of extending preventive care and health insurance to children, however, is somewhat less contentious [than providing insurance to adults], largely because children are viewed more sympathetically than adults by health care leaders and the American public.

Hughes et al. argue for immediate universal coverage for children, rather than waiting for universal coverage for the country as a whole and note that it would have to occur at the federal, as opposed to state and local, levels.  They make two recommendations for achieving this goal.

One option is to create a Medicare-like federal program under which all children are automatically enrolled in a comprehensive insurance program, regardless of income. By and large, Medicare works well for seniors and is a reasonable model for children. Another option involves modifying Medicaid, SCHIP, and other categorical programs to create a uniform insurance program for low-income and undocumented children that eliminates the confusion and complexity associated with multiple programs. Both options would require sufficient minimization of paperwork and reimbursement to providers to ensure that coverage translates into genuine access to care.

Hughes et al. point out that most Americans support universal coverage, especially for children, despite the added tax burden it may cause.  This is probably a sentiment reflecting the reality of the extreme cost and gross inefficiency of the American health care system.  As children constitute a categorically vulnerable population which affords them the sympathy of the country, it makes sense to begin the road to universal health care in this country with them.  The vast majority of taxpayers are willing to foot the bill and we have an administration ripened to bring about such a change.  If ever there was the time to begin the process of providing universal health insurance to children in America, it would be now.

Surprise, Surprise: Older Americans are Sicker than their European Counterparts

In this international study, we found that US adults of all wealth levels reported worse health than did Europeans at comparable wealth levels.  Poor Americans were at particularly worse health compared with their English or other European counterparts, but even well-off Americans reported health comparable to substantially poorer Europeans.  Differences in behavioral risk factors accounted for only a fraction of these disparities.

As behavioral factors were insufficient to account for this disparity, Avendano et al. distinguish between national health care systems.

Features of the US health care system may contribute to the worse health of Americans compared with Europeans.  In particular, most European countries have a stronger primary care orientation than does the United States.  Previous evidence suggests that a strong primary care system is associated with better health outcomes, partly because it entails a stronger focus on primary prevention, a more equitable distribution of resources, and a higher efficacy of the health system.

Investing less at the primary care stage where prevention is key, necessarily means that there is a greater focus on disease maintenance or amelioration after its onset.  Which is to say that Americans, for the most part, are not afforded significant medical attention until they are sick.

In addition to having a stronger focus on primary care than the United States, European countries have greater protections for their poor.  European countries offer virtually universal health care coverage, so even the poor have relatively unfettered access to necessary care.  The United States on the other hand, has an uninsured population totaling 41 million (or over 45 million by some estimates).

The fact that health disparities in England still persists despite access to care,

suggests that mechanisms outside the health care system may also be involved.  Wealth enhances access to material resources such as housing, and is a source of immediate consumption in periods of economic strain. Wealth may also increase sense of control over life and other psychosocial resources that can enhance health.

This study gives further credence to the notion that America has at least something to learn from the European health care system.  Universal health care is one component, but focusing more keenly on primary care and easing the social burdens of the poor are another.  Racial health disparities is also an issue that has to be addressed in the United States, but this study restricted its study population to non-Hispanic Whites in order to determine what factors beyond those attributable to race are at issue in the United States’ lag behind its European peers.  Given the fact that racial health disparities are prevalent in the United States, it would not strain reason to conclude that the gap between Americans and Europeans would be exacerbated if racial minorities were included.  The correlation between economic status, residential segregation and well being may help explain why this is the case.

The United States health care system clearly demonstrates that dollars spent is no indication of the quality or efficacy of health care actually received.  Moving into a more cost-effective health care  paradigm that provides access to comprehensive care at a stage where it can impact long-term health is essential.  The Avendano study offers proof of this.