Preventive Medicine
August 4, 2008 6:24 AM Subscribe
Are expensive, precautionary tests for health preventive maintenance an abuse of the medical system?
We change the oil, belts, and filters in our cars on a regular basis to avoid failure. We update our computers appropriately with the latest security patches. Women get mammograms, men prostate screenings. Occasional chest x-rays have become routine. But what about the more expensive diagnostic testing?
My grandfather died of heart disease. My father survived a heart attack when he was 52, but has had two angioplasty procedures since. Obviously, at age 55, I am at high risk for heart disease, but am otherwise very healthy. A couple years ago I talked with my physician about testing my arteries before they clog or blow. He ordered a preventive stress test, and everything looked rosey.
Is this kind of testing abusive? How about MRI or CT-scan for those with a family history of stroke? Will this kind of preventive testing cause insurance rates to go up for everyone? Should it be more common? Thanks in advance for your help.
We change the oil, belts, and filters in our cars on a regular basis to avoid failure. We update our computers appropriately with the latest security patches. Women get mammograms, men prostate screenings. Occasional chest x-rays have become routine. But what about the more expensive diagnostic testing?
My grandfather died of heart disease. My father survived a heart attack when he was 52, but has had two angioplasty procedures since. Obviously, at age 55, I am at high risk for heart disease, but am otherwise very healthy. A couple years ago I talked with my physician about testing my arteries before they clog or blow. He ordered a preventive stress test, and everything looked rosey.
Is this kind of testing abusive? How about MRI or CT-scan for those with a family history of stroke? Will this kind of preventive testing cause insurance rates to go up for everyone? Should it be more common? Thanks in advance for your help.
Also, I don't understand why you would consider your test to be potentially abusive. You're high risk because of your family history. Your doctor needs to know that your present status is OK.
Also also, I can speak from very recent personal experience that an MRI by itself costs much less than a 3-day hospital stay. It would be painful to pay for it without insurance, but doable for most people.
posted by desjardins at 6:51 AM on August 4, 2008
Also also, I can speak from very recent personal experience that an MRI by itself costs much less than a 3-day hospital stay. It would be painful to pay for it without insurance, but doable for most people.
posted by desjardins at 6:51 AM on August 4, 2008
There is a growing, if slow, movement towards preventive care in the health industry. Ultimately it is cheaper to prevent disease than to treat it. Look at the cost of a pap test vs. the cost of treating cervical cancer. Catch things early and nip them in the bud.
A lot of this shift towards primary care means lifestyle changes, but a lot of it also means checkups and screening. They cost money, but less than treating lots of sick people.
posted by Askr at 7:26 AM on August 4, 2008
A lot of this shift towards primary care means lifestyle changes, but a lot of it also means checkups and screening. They cost money, but less than treating lots of sick people.
posted by Askr at 7:26 AM on August 4, 2008
Tests in high-risk patients are certainly appropriate; this is especially true in cases such as heart disease where they can help guide interventions (exercise, stop smoking, treat elevated cholesterol, etc.) that might prevent a heart attack, thus saving money in the long run. Without knowing more I can't say for sure if the test was appropriate for you, but insurers look pretty closely at these things, going as far as to provide financial rewards to physicians who keep tests to a minimum. As for strokes, there are tests that can be helpful there, too, but the appropriate tests will be different accordiing to what kind of stroke you are concerned about
posted by TedW at 7:33 AM on August 4, 2008
posted by TedW at 7:33 AM on August 4, 2008
I knew I was having some sort of heart trouble in 1999, was in bed with ol' Sandy from San Antone, always fun, but then things got too good, if you catch my drift. I went to my physician, he did a EKG in his office and found nothing, sent me to Austin Heart Hospital and they put me on a stress test and found nothing, sent me on my way. I stayed away from Sandy, for any number of reasons, from then on.
Four years later I'm dead as Dillinger, heart attacks, from a cardiac artery problem, congenital, from Dear Sweet Mom. They didn't find it with the tests that they had in 1999 and 2000 but with the tests that are available today they'd have prevented me just all kinds of grief, not to mention huge expense.
One year later, almost to the day, my mother had the exact same heart attack, from the exact same problem in her cardiac artery. She'd broken her leg, was in the hospital when it happened, so she didn't die, in fact didn't have much problem at all -- they popped the stent in, same as they did me, all was/is well.
If you intend to have a heart attack, I can't recommend highly enough that you do so in the hospital, rather than a friends pickup truck on the way to the hospital, stuck in rush hour traffic; it's just all-around a much better experience.
Every one of my sibs have since been tested, using currently available technology -- so far so good.
Testing is not abusive. It makes good sense, esp if you have a history in your family.
posted by dancestoblue at 7:59 AM on August 4, 2008
Four years later I'm dead as Dillinger, heart attacks, from a cardiac artery problem, congenital, from Dear Sweet Mom. They didn't find it with the tests that they had in 1999 and 2000 but with the tests that are available today they'd have prevented me just all kinds of grief, not to mention huge expense.
One year later, almost to the day, my mother had the exact same heart attack, from the exact same problem in her cardiac artery. She'd broken her leg, was in the hospital when it happened, so she didn't die, in fact didn't have much problem at all -- they popped the stent in, same as they did me, all was/is well.
If you intend to have a heart attack, I can't recommend highly enough that you do so in the hospital, rather than a friends pickup truck on the way to the hospital, stuck in rush hour traffic; it's just all-around a much better experience.
Every one of my sibs have since been tested, using currently available technology -- so far so good.
Testing is not abusive. It makes good sense, esp if you have a history in your family.
posted by dancestoblue at 7:59 AM on August 4, 2008
I'm not sure exactly what you mean when you ask whether preventive tests are "abusive," but there are a lot of health economists out there grappling with the question of what the upsides and downsides of routine screenings and preventive care are, both for specific tests and in general.
If you wanted to do some research into the specific tests you underwent and whether they are recommended (other than talking with your doctor, of course!), a good place to start would be the U.S. Preventive Services Task Force. This is a group that was put together in 1984 to evaluate what sorts of tests and care are appropriate preventive care for adults based on clinical evidence. (So they generally sidestep the question of whether a particular screening is "worth the money" on a systems level, and merely focus on whether a patient is likely to be better of for having been screened regardless of cost.)
There's a bunch of interrelated concepts when you start thinking about whether a specific screening is "worth" the cost, which seems to be at the heart of your question. The most commonly argued idea is that preventive care is cost-saving, which means that all else being equal, screening people leads to so much money being saved by catching things early that you end up with extra money at the end (as Askr is arguing above). This is very, very, very rarely true. I can't find the cite right now (sorry--if you're very interested, memail me and I'll scrounge around my computer some more), but in general the only things that have been shown to be cost-saving are vaccinations and other low-cost screenings for kids and adolescents. Among adults, the population that is most likely to generate cost-savings by undergoing screenings and more extensive preventive care is almost exactly the population that doesn't go to the doctor at all, which is why disease-management programs have such a hard time creating savings--anyone who would participate is probably the sort of person who doesn't need such a program in the first place.
Beyond the relatively simple concept of cost-savings, you can get into cost-effectiveness, which assumes that health has an intrinsic value and thus we shouldn't rely on actually saving money to determine whether a particular screening or procedure is worth doing. However, the nature of that is you can only ask whether procedure A is more cost-effective than procedure B for the benefit you get, not whether it's worth it to do procedure A or procedure B in the first place. The latter question is ultimately a value judgment: if the screening you underwent cost $10,000 (hypothetically), and it had a 1% chance of catching something that might have ended up to be fatal, is that worth it? People have different answers to that question. It's obviously further complicated when it's not just your money that you're spending, but the pooled money of everyone who has paid premiums to your health insurer.
The last place you might want to look if you're interested in the question of the benefit vs. costs of screenings and preventive care is into the work of Wennberg and his colleagues at Dartmouth. They've spent a long time looking at regional variations in the amount of health care that Medicare beneficiaries receive (that is, mostly people over 65), and whether more preventive care leads to better outcomes. This article, originally published in JAMA, gives a pretty good overview of their argument, which is that increasing the level of screenings you undergo does not necessarily lead to better outcomes. Rather, it increases the likelihood that you'll trigger a cascade of more intensive interventions, which may leave you worse off (or no better off) than if you'd not undergone screening at all. However, this research is very much at the population level, not the individual level--so the question of whether it was wise for you, individually, to undergo those screenings depends on your history and risk factors, which I assume your doctor took into account.
Apologies for the novel above! The question you're asking is a really complicated one, and a very interesting one. I'm not familiar with all the literature, but I have a good idea of where the major work on different topics is being done, so if you'd like pointers to different articles or authors on anything I've mentioned above just memail me.
posted by iminurmefi at 8:30 AM on August 4, 2008 [3 favorites]
If you wanted to do some research into the specific tests you underwent and whether they are recommended (other than talking with your doctor, of course!), a good place to start would be the U.S. Preventive Services Task Force. This is a group that was put together in 1984 to evaluate what sorts of tests and care are appropriate preventive care for adults based on clinical evidence. (So they generally sidestep the question of whether a particular screening is "worth the money" on a systems level, and merely focus on whether a patient is likely to be better of for having been screened regardless of cost.)
There's a bunch of interrelated concepts when you start thinking about whether a specific screening is "worth" the cost, which seems to be at the heart of your question. The most commonly argued idea is that preventive care is cost-saving, which means that all else being equal, screening people leads to so much money being saved by catching things early that you end up with extra money at the end (as Askr is arguing above). This is very, very, very rarely true. I can't find the cite right now (sorry--if you're very interested, memail me and I'll scrounge around my computer some more), but in general the only things that have been shown to be cost-saving are vaccinations and other low-cost screenings for kids and adolescents. Among adults, the population that is most likely to generate cost-savings by undergoing screenings and more extensive preventive care is almost exactly the population that doesn't go to the doctor at all, which is why disease-management programs have such a hard time creating savings--anyone who would participate is probably the sort of person who doesn't need such a program in the first place.
Beyond the relatively simple concept of cost-savings, you can get into cost-effectiveness, which assumes that health has an intrinsic value and thus we shouldn't rely on actually saving money to determine whether a particular screening or procedure is worth doing. However, the nature of that is you can only ask whether procedure A is more cost-effective than procedure B for the benefit you get, not whether it's worth it to do procedure A or procedure B in the first place. The latter question is ultimately a value judgment: if the screening you underwent cost $10,000 (hypothetically), and it had a 1% chance of catching something that might have ended up to be fatal, is that worth it? People have different answers to that question. It's obviously further complicated when it's not just your money that you're spending, but the pooled money of everyone who has paid premiums to your health insurer.
The last place you might want to look if you're interested in the question of the benefit vs. costs of screenings and preventive care is into the work of Wennberg and his colleagues at Dartmouth. They've spent a long time looking at regional variations in the amount of health care that Medicare beneficiaries receive (that is, mostly people over 65), and whether more preventive care leads to better outcomes. This article, originally published in JAMA, gives a pretty good overview of their argument, which is that increasing the level of screenings you undergo does not necessarily lead to better outcomes. Rather, it increases the likelihood that you'll trigger a cascade of more intensive interventions, which may leave you worse off (or no better off) than if you'd not undergone screening at all. However, this research is very much at the population level, not the individual level--so the question of whether it was wise for you, individually, to undergo those screenings depends on your history and risk factors, which I assume your doctor took into account.
Apologies for the novel above! The question you're asking is a really complicated one, and a very interesting one. I'm not familiar with all the literature, but I have a good idea of where the major work on different topics is being done, so if you'd like pointers to different articles or authors on anything I've mentioned above just memail me.
posted by iminurmefi at 8:30 AM on August 4, 2008 [3 favorites]
individually, for screening tests you might want to consider several things:
(1) the pre-test probability, your likelihood of having something based on epidemiological data and clinical signs.
(2) whether the test results will alter the decision-making process (they surprisingly might not.)
(3) Whether early diagnosis can affect outcomes compared to a regular diagnosis. (knowing something ahead of time might not help )
At a population level, it is worth looking at the Quality-Adjusted Life Year (QALY) cost of a screening procedure. One notable case is whether it is reasonable to use CT scans to screen current and ex-smokers for lung cancer. Some people calculated the QALY for CT's for current smokers at $116,300 and for ex-smokers at $2,322,700.
posted by alex3005 at 9:49 AM on August 4, 2008
(1) the pre-test probability, your likelihood of having something based on epidemiological data and clinical signs.
(2) whether the test results will alter the decision-making process (they surprisingly might not.)
(3) Whether early diagnosis can affect outcomes compared to a regular diagnosis. (knowing something ahead of time might not help )
At a population level, it is worth looking at the Quality-Adjusted Life Year (QALY) cost of a screening procedure. One notable case is whether it is reasonable to use CT scans to screen current and ex-smokers for lung cancer. Some people calculated the QALY for CT's for current smokers at $116,300 and for ex-smokers at $2,322,700.
posted by alex3005 at 9:49 AM on August 4, 2008
Abusive to whom? Preventive testing done properly saves lives and money. Preventive testing, done without need, leads to unneeded medication and unneeded further tests and unneeded invasive procedures which cost the whole system more and make the patient worry needlessly and put him at risk for complications from procedures he didn't need.
Many people believe our system currently incentivizes physicians to do more tests and prescribe more drugs than needed. We've got both overprescribing and underprescribing, over treatment and undertreatment and an insane system that doesn't help anyone except maybe the insurance companies.
Nortin Hadler's "Worried Sick" takes an interesting (if complicated!) perspective, opposing mammograms, colonoscopies and most heart procedures as not worth the bother. Most American physicians take the opposite view-- but he's definitely got good data for many of his points.
It depends, basically on whether you worry more about going to the doctor all the time and having lots of unpleasant tests and worrying about results or whether you worry more that not doing this will put you at risk for a preventable thing that will kill you before a nonpreventable thing will.
posted by Maias at 1:25 PM on August 4, 2008
Many people believe our system currently incentivizes physicians to do more tests and prescribe more drugs than needed. We've got both overprescribing and underprescribing, over treatment and undertreatment and an insane system that doesn't help anyone except maybe the insurance companies.
Nortin Hadler's "Worried Sick" takes an interesting (if complicated!) perspective, opposing mammograms, colonoscopies and most heart procedures as not worth the bother. Most American physicians take the opposite view-- but he's definitely got good data for many of his points.
It depends, basically on whether you worry more about going to the doctor all the time and having lots of unpleasant tests and worrying about results or whether you worry more that not doing this will put you at risk for a preventable thing that will kill you before a nonpreventable thing will.
posted by Maias at 1:25 PM on August 4, 2008
The only thing I would add to iminurmefi's excellent answer is that doing a cardiac stress test in an asymptomatic person who is at increased risk for coronary artery disease is currently a gray area and would be considered a "reasonable" thing to do by many physicians, although it is not, in my experience, routinely done by most primary care physicians.
posted by Slarty Bartfast at 4:49 PM on August 4, 2008
posted by Slarty Bartfast at 4:49 PM on August 4, 2008
Are you kidding? Is this a serious question? The prophylactic testing doctors do pays huge real-world money dividends. Your dad's first hospitalization for MI could have paid for 100 outpatient stress tests. If a stress test could have resulted in prophylactic therapy, even delaying it for 5 years, the benefit to payors and to society overall (your dad works, right? I mean, when he's not at death's door in the hospital, right?) would be quantifiable and gargantuan.
I'm always baffled when my patients worry that too much is being spent to keep them healthy. I can only conclude that they have no idea how much it costs the health care system and society when they get sick. Prophylactic testing and therapy is not where the abuse and waste is in today's healthcare system. Please tilt at a different windmill.
posted by ikkyu2 at 8:54 PM on August 4, 2008 [1 favorite]
I'm always baffled when my patients worry that too much is being spent to keep them healthy. I can only conclude that they have no idea how much it costs the health care system and society when they get sick. Prophylactic testing and therapy is not where the abuse and waste is in today's healthcare system. Please tilt at a different windmill.
posted by ikkyu2 at 8:54 PM on August 4, 2008 [1 favorite]
Reading iminurmefi's answer leaves me shaking my head. This kind of analysis - the one that assumes that health has no value and days of productive work lost has no value - is the same kind of analysis that suggests that people should be encouraged to smoke cigarettes because it rolls back their average lifespan from 80 to 65, neatly coinciding with the date of their retirement from the workforce. If you really want to look at it that way - that retired people are a drain on health care resources and there is no benefit to keeping them alive - then yes, prophylactic testing for older folks is always cost-ineffective, as is caring for them instead of letting them die when they get sick.
Cardiac screening for 55 year olds with pertinent risk factors, like a strong family history of early cardiac disease, is indicated and saves money. Check out Framingham.
posted by ikkyu2 at 8:59 PM on August 4, 2008
Cardiac screening for 55 year olds with pertinent risk factors, like a strong family history of early cardiac disease, is indicated and saves money. Check out Framingham.
posted by ikkyu2 at 8:59 PM on August 4, 2008
Hmm, reading ikkyu2's answer makes me fear that netbros might misunderstand my answer, which certainly wasn't intended to convey that "health has no value."
In fact, I think that people's often-misguided (or at least imprecise) claim that preventive care "saves money" has moved the goalposts politically in a way that ultimately makes it more difficult to pass legislation that expands health care programs. There are very few other state or federal programs that are expected to pass the "saves money" standard in order to be considered successful (the only one I can think of off the top of my head is prison rehabilitation programs). Unfortunately, many innovative programs in Medicare and Medicaid--everything from disease management to pay-for-performance quality standards to electronic medical records--are "sold" on the promise that implementing the program will result in a lower cost overall than failing to implement the program. Not surprisingly, this is a standard which is rarely met, making it difficult to sustain those programs even when they demonstrate better health outcomes for actual patients. (It's easier to merely evaluate whether specific types of preventive care and screenings actually do lead to better outcomes, which was the point of the two links I included above. I think it's somewhat surprising and counterintuitive that more tests might leave you worse off, and I do think that needs to be considered before you even get to questions of relative costs.)
Shifting the question from one about cost-saving to one about cost-effectiveness implicitly assumes that health does have some intrinsic value and is worth paying for, and we should merely look for the lowest-cost way to attain a given level of health. The problem with this is that the question of how much health is worth is ultimately a value judgment, and doesn't really have an objective answer. I'm trying to point out that netbros's question is one that is, at its heart, a value judgment: is it a good thing or a bad thing for insurance to be slightly more expensive and cover more preventive care? The answer to that is probably different for different people, and depends on how big a problem you think it is for people to be priced out of the insurance market versus the benefit of lowering mortality and disease burden among those who are still able to afford insurance.
posted by iminurmefi at 8:21 AM on August 5, 2008
In fact, I think that people's often-misguided (or at least imprecise) claim that preventive care "saves money" has moved the goalposts politically in a way that ultimately makes it more difficult to pass legislation that expands health care programs. There are very few other state or federal programs that are expected to pass the "saves money" standard in order to be considered successful (the only one I can think of off the top of my head is prison rehabilitation programs). Unfortunately, many innovative programs in Medicare and Medicaid--everything from disease management to pay-for-performance quality standards to electronic medical records--are "sold" on the promise that implementing the program will result in a lower cost overall than failing to implement the program. Not surprisingly, this is a standard which is rarely met, making it difficult to sustain those programs even when they demonstrate better health outcomes for actual patients. (It's easier to merely evaluate whether specific types of preventive care and screenings actually do lead to better outcomes, which was the point of the two links I included above. I think it's somewhat surprising and counterintuitive that more tests might leave you worse off, and I do think that needs to be considered before you even get to questions of relative costs.)
Shifting the question from one about cost-saving to one about cost-effectiveness implicitly assumes that health does have some intrinsic value and is worth paying for, and we should merely look for the lowest-cost way to attain a given level of health. The problem with this is that the question of how much health is worth is ultimately a value judgment, and doesn't really have an objective answer. I'm trying to point out that netbros's question is one that is, at its heart, a value judgment: is it a good thing or a bad thing for insurance to be slightly more expensive and cover more preventive care? The answer to that is probably different for different people, and depends on how big a problem you think it is for people to be priced out of the insurance market versus the benefit of lowering mortality and disease burden among those who are still able to afford insurance.
posted by iminurmefi at 8:21 AM on August 5, 2008
Evidence-based practice guidelines for preventative care, courtesy of the US Preventative Services task force.
Would you do away with prescription coverage for anticonvulsants, iminurmefi? Let's say a guy has 12 seizures a year off drugs, 0 seizures a year on drugs. 12 emergency room visits at $10,000 a pop - $120,000. 1 year of Tegretol - $400. Plus, the guy having seizures all the time can't drive and hence loses his job, resulting in a loss to society of $50,000 in useful work. Never mind the head trauma, shoulder dislocations, etc. suffered during the seizures.
And yet, when I give someone anticonvulsants - or a $50,000 seizure surgery intended to cure - I'm engaging in "preventative care."
Most preventative care saves society a lot of money - not all of it, of course. There's some evidence, for instance, that full-body CT or nuclide scans of people thought to be otherwise healthy do detect a few asymptomatic cancers, early, before they spread - and yet they cost way too much to be using on a regular basis. This is where the value judgments mentioned by iminurmefi come in - not in the case of routine preventative care, like a cardiac EKG stress test using Bruce treadmill protocol for a 55 year old with a family history of precocious coronary artery disease.
posted by ikkyu2 at 9:18 AM on August 5, 2008
Would you do away with prescription coverage for anticonvulsants, iminurmefi? Let's say a guy has 12 seizures a year off drugs, 0 seizures a year on drugs. 12 emergency room visits at $10,000 a pop - $120,000. 1 year of Tegretol - $400. Plus, the guy having seizures all the time can't drive and hence loses his job, resulting in a loss to society of $50,000 in useful work. Never mind the head trauma, shoulder dislocations, etc. suffered during the seizures.
And yet, when I give someone anticonvulsants - or a $50,000 seizure surgery intended to cure - I'm engaging in "preventative care."
Most preventative care saves society a lot of money - not all of it, of course. There's some evidence, for instance, that full-body CT or nuclide scans of people thought to be otherwise healthy do detect a few asymptomatic cancers, early, before they spread - and yet they cost way too much to be using on a regular basis. This is where the value judgments mentioned by iminurmefi come in - not in the case of routine preventative care, like a cardiac EKG stress test using Bruce treadmill protocol for a 55 year old with a family history of precocious coronary artery disease.
posted by ikkyu2 at 9:18 AM on August 5, 2008
recent news of interest, recommendation against prostate cancer screening in men ages 75 or older.
posted by alex3005 at 10:57 AM on August 5, 2008
posted by alex3005 at 10:57 AM on August 5, 2008
How many changes are you willing to make based on these tests? Some people are unwilling to make lifestyle changes to take of themselves even with the knowledge that testing provides. If you have the stress test and use that knowledge to make changes to reduce your risk (lower your cholesterol, maintain a healthy body weight, increase you fitness), then the test is not a waste.
posted by 26.2 at 7:37 AM on August 12, 2008
posted by 26.2 at 7:37 AM on August 12, 2008
Response by poster: Thank you everyone for the thoughtful answers.
posted by netbros at 10:59 AM on September 4, 2008
posted by netbros at 10:59 AM on September 4, 2008
This thread is closed to new comments.
IANANeurologist but I don't know that an MRI can catch a stroke unless it's impending.
posted by desjardins at 6:48 AM on August 4, 2008