Sunday, September 1, 2013

Too Much Health Care Can Be Hazardous to Your Health

If there is one trend that epitomizes the overconsumption of health care, it’s executive physicals. These in-depth half-day examinations, which often include extensive scanning, almost always reveal something, whether it’s truly there or not. I’ll let our colleague David McCann, editor of CFO Magazine, tell a story. You want to listen to this guy.

A good friend of mine underwent a “full-body screening” and a few suspicious cells were detected in his lung. So he had surgery, during which a hunk of one lung was removed. It was a difficult surgery, as you would imagine, and it took him a long time to recover. There was, of course, no cancer. Meanwhile, I had talked to my brother, who’s a radiologist, who literally smacked himself in the forehead when he heard the story and said, “Every single person has suspicious cells. These full-body screenings and the surgeries they lead to are a shameful scam.”

Far from being a rarity, findings like these — which often lead to surgeries like his — are so common that radiologists even have a disparaging name for them: “incidentalomas.” Doctors can’t ignore them — someone could sue if they truly turn out to be cancerous. Hence the finding itself creates the need for the surgery. Further, Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch, Lisa Schwartz, and Steve Woloshin describes how the steady increase in imaging resolution is creating a parallel steady increase in these incidentalomas. For this and many other reasons, I strongly recommend against executive physicals, especially those involving scanning.

No sooner had I written this paragraph than the AHIP Smartbrief, which has never met a wellness intervention it didn’t like, trumpeted exactly this situation. Via Christi Hospital’s half-day screens for Intrust Bank leadership revealed an average of 1.1 new diagnoses per executive (on top of whatever diagnoses they already had, of course), most of which would need to be followed up with doctors and possibly diagnostics and treatments. The bank’s spokesperson, in an understatement worthy of induction into the Wellness Ignorati Hall of Fame, observed: “It’s still too early to see financial savings.”

Via Christi’s spokesperson was a bit blunter, admitting that these screens and follow-ups “offer another source of income” for the hospital.

The equivalent of the half-day executive physical for those of us in the “99 percent” is the biometric screen. Companywide screens are one of the many things that doctors are by and large opposed to (see the Wall Street Journal, Feb. 20, 2013), the federal government eschews (the National Heart, Lung and Blood Institute recommends only once every five years for healthy working-age adults) but that the ignorati seemingly can’t get enough of.

The good news about those screens is they will identify people at high risk for diabetes, one of the two diseases they most often target, and get them into a program well before they develop diabetes. The bad news (among other things) is that the evidence indicates that there is no difference in outcomes between people at high risk for diabetes who get screened and get early intervention and those who don’t.

Renowned British medical journal The Lancet published a major study in November 2012 showing results of screenings followed by 10 years of follow-up on more than 20,000 people. This study was conducted according to tight academic specifications (requirements include having a hypothesis to be tested, statistically significant samples, a control, blinding, and so forth), as opposed to wellness industry specifications (requirements include owning a laptop). And because Britain has a national health system, follow-up was relatively straightforward. The results were unequivocal: There was zero health benefit to early screening in people without actual diabetes, if, like most diabetics, they received usual care for the next 10 years.

This result justifies the U.S. Preventive Services Task Force’s 2008 recommendation to restrict diabetes screening in the under-65 population to just those people with increased blood pressure. However, it doesn’t justify the section heading that too much health care is hazardous to your health (with full-body screens being a major exception), just that screening isn’t necessarily helpful to your health. Read on.

Along with diabetes, the other major focus of these biometric screens is heart disease. Heart disease is no doubt a killer, and there are sobering statistics somewhere about the number of people experiencing preventable heart attacks every year. Fortunately, “sobering” is not a synonym for “correct,” and if a statistic about preventable heart disease strikes you as sobering, it is probably because it’s wrong.

There is no correlation between the rate of cardiac testing and procedures in a given geography and the rate of heart attacks.

Here is the rather nonsobering actual statistic: the annual rate of heart attacks in the commercially insured working-age population is only about 1 in 500. Next, let’s add some educated guesswork. Feel free to substitute your own guesses — they won’t change the overall answer:

  • If you omit the people with known risk factors or pre-existing heart disease — people who don’t need the screening because they already know they are at risk — that number falls to about 1 in 2,000.
  • If you then count only the people who could have their heart disease detected via a rudimentary screen, thereby eliminating those whose subsequent heart attacks are not readily predictable, that number falls further, possibly to about 1 in 4,000. This ratio in reality is probably even more unfavorable, as cholesterol, particularly the “bad” cholesterol, turns out to be a very primitive marker for heart disease, both overinclusive (leading to much more treatment) and underpredictive (many people with acceptable “bad” cholesterol nonetheless have heart attacks).

So a $40 biometric screen will find at best one avoidable heart attack in every 4,000 people ... at a cost of $160,000. Add in, for instance, $200 in incentives and $20 in time off from work to persuade people to participate, and you’ve now created the million-dollar heart attack screen.

And keep in mind that find is not the same as avoid. I don’t think anyone has statistics on what proportion of potential heart attacks are avoided. If we generously assume that fully half of avoidable heart attacks can indeed be avoided, the cost per avoidable heart attack that actually is avoided becomes $2 million.

You might say at this point: “Well, maybe I can’t justify spending $2 million in purely economic terms to prevent an employee from having a heart attack (which typically costs five figures to treat and recover from, including follow-up and lost work time). But a heart attack entails a human cost of pain, suffering, and possibly even risk of death, as well. And I would happily spend 2 million bucks to avoid that cost.”

A well-intentioned thought, to be sure. But the trouble is that you don’t know which one of the people being screened as being high-risk is going to be that 1 in 4,000. And that’s where the “too much health care can be hazardous to your health” part comes in. Two to three percent of the people screened — about 1 in 40 — will be instructed to follow up with their doctors. Follow the arithmetic here: 1 in 40 means that 100 people will get referred. However, only one of the people receiving this advice would actually have a heart attack if he or she failed to do so (and may even have one anyway, despite that follow-up care). But those other 99 will get extra doctor visits, prescriptions, and possibly cardiologist referrals. And cardiologists almost always order further testing, since their professional risk of doing nothing is quite high.

What is the result of “almost always ordering further testing”? According to Overtreated author Shannon Brownlee, invasive cardiac testing and procedures are performed almost 2 million times a year. To put this in perspective, the number of babies born in the United States is only about twice that. So at current rates of testing and procedures, half of all people will eventually have an average of one invasive test or procedure. Are our hearts so fragile or ill-evolved that such a massive proportion of our population needs (at a minimum) dye injected into them to make sure they are pumping correctly? Take a look at your own company’s heart attack rates — that 1 in 500 figure won’t be far off — and then decide if reducing that overall 1-in-500 annual chance to perhaps 1-in-1,000 is worth sending half your employees for invasive testing at some point. (Admittedly, that statistic is a little misleading because many of those employees wouldn’t get the invasive test until after they retire.)

And here are your chances of success: Once the substantial countrywide decline in heart events is taken into account, no company or health plan ever measured covering more than 100,000 people — about the level at which you can be sure of a result — has ever reduced that rate by half once the secular decline in heart attacks is taken into account, even over 10 years.

You might be thinking, “Especially considering the small chance of success, that sounds like a lot of inappropriateness.” But I haven’t even gotten to the inappropriate part yet. With the exceptions of cardiac procedures actually being done in the throes of a heart attack (U.S. medicine at its best: timely, responsive, and effective) and a few other clearly delineated cohorts, there is no clear evidence that these procedures actually help people to avoid heart attacks, as Overtreated shows at length. Among other pieces of evidence, there is no correlation between the rate of cardiac testing and procedures in a given geography and the rate of heart attacks.

Many primary care doctors know this. Paul Levy, who formerly ran Beth Israel Deaconess Hospital in Boston, recalls the time he needed a stress test as a requirement for participating in an ocean kayaking trip in Patagonia. His PCP refused to order it. She said: “Because he knows who you are, the cardiologist will be especially attuned to any odd peculiarity about your heartbeat. He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication and you will end up being harmed. But the reality is that whatever peculiarity he finds has probably existed for decades. There is no history of heart disease in your family. You cycle 100 miles per week and play soccer for hours every week, and you have never had a symptom that would indicate a circulatory problem. Therefore, I will not authorize a stress test.”

Also, the literature is quite clear that stenting people without unstable angina has no better outcomes than the diet-and-exercise solution. But because a stent is “doing something” and (see first section) basically free, many if not most people will follow the doctor’s recommendation and have stents inserted.

Still, the doctor is the professional, and he has all the data in front of him and is working on your employees’ behalf. So he wouldn’t recommend an invasive procedure unless it was truly indicated... or would he? He just might.

Authors: Tom Emerick, president of Emerick Consulting, was with Walmart for many years. One of his duties involved managing benefits for over 1.3 million employees. Al Lewis is the president of the Disease Management Purchasing Consortium. Earlier he taught economics at Harvard, held management positions at Interqual and Bain Capital, and was an analyst at Lehman Brothers.