Promoted from the Ricochet Member Feed by Editors Created with Sketch. Preventing Preventive Medicine

DrRich
By DrRich
DrRich Inactive
Former professor of medicine, and practitioner of cardiac electrophysiology. Currently eking out a living as writer and consultant. President, founder and sole member of Glorious Old Farts of America (GOFA). Proprietor of facebook.com/secretcardiology
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45 COMMENTS
 

mammograms_health_care_reform_091120_wmainThe American Cancer Society has just released new breast cancer screening guidelines that substantially scale back its previous recommendations. They move much closer to the controversial recommendations made by the United States Preventive Services Task Force (USPSTF) in 2009. According to the ACS, screening should now be delayed until age 45, with annual screening until age 55, then biannual screening until age 75, when screening should stop. These new recommendations meet the USPSTF roughly halfway. (Until this week, the ACS recommended annual screening after age 40.)

I am no cancer specialist, but merely a simple country cardiac electrophysiologist. In general, I still have a residual amount of trust in the ACS (as opposed to, for instance, the American Heart Association). So I am open to the idea that the new ACS recommendations may in some way be reasonable.

However, admittedly without any direct evidence, I suspect that the ACS has instead chosen to interpret available clinical evidence in a way that moves them closer to the USPSTF, as a matter of institutional survival. For it will not pay, in the long run, for any professional organization to get on the wrong side of the USPSTF.

This is because the Obamacare legislation converted the formerly unobtrusive and mild-mannered USPSTF (which for many years had made polite recommendations that it hoped doctors might take into account on occasion, and which sometimes they did) to the final arbiter of which preventive services would be offered, which could not be offered, when, and to whom. Whatsoever the USPSTF may bind on earth will be bound in heaven, and whatever the USPSTF loose on earth will be loosed in heaven.

To illustrate: The 2009 mammography “recommendations” by the USPSTF were so inflammatory that they threatened to upend the pending Obamacare legislation itself at a critical juncture. To put out the fire, Secretary Sibelius immediately announced that, of course, these were mere recommendations, and, of course, women and doctors could decide for themselves when and how often to do mammography. But then, to render her patently false statement true, Congress was obligated to quickly amend the legislation to specifically exempt mammography from the restrictions imposed by the USPSTF on all other preventive services. (See Section 2713.)

There is a very good reason why Obamacare took complete control over preventive services, which is: Preventive services must be curtailed as much as possible.

I realize how upside-down this sounds. Speaker Pelosi herself famously declared that Obamacare is all about “prevention, prevention and prevention!” But here’s the sad fact. Preventive healthcare services cost the healthcare system far more money than they can ever save; for this reason, any healthcare system in which costs are paid collectively is going to have to find a way to stifle these preventive services.

While this statement may initially seem counter-intuitive, a few moments of thought will show you the truth of it:

  1. The preventive measure itself costs money.
  2. The preventive measure may not be very effective.
  3. Many “preventive healthcare services” consist of some kind of screening test for “early detection,” and these screening tests almost always produce more false positive results than true positive results — leading to the need for more definitive, more expensive, and often invasive confirmatory tests.
  4. “Early detection” of any medical condition often detects “occult” disease that might never become manifest.
  5. Treating the diagnosed — and often occult — medical condition often costs a great deal and produces expensive complications. And it is often ineffective.
  6. Often, early treatment of many medical conditions won’t lead to a cure, but will instead convert what would likely have been a relatively short and fatal (i.e., relatively inexpensive) disease to a much more chronic, much more expensive disease.
  7. Spending money to prevent a particular medical condition gives the beneficiary the time to develop some other medical condition – possibly a much more expensive one – in the future.
  8. If the patient whose life is saved by the screening test and subsequent therapy is an Old Fart (like myself), that patient will persist, for several more years, to soak younger, worthier Americans for Social Security and Medicare payments.

Q.E.D. The healthcare system will spend far more money by offering these preventive services than by not offering them.

This result should not be very surprising. It is the natural result when healthcare services are paid for collectively.

Consider what would happen if smoke detectors were regarded as a preventive medical service. Smoke detectors clearly save lives here and there. But we cannot show any real data proving that the overall survival of Americans who have smoke detectors is significantly higher than of Americans who don’t. So if it were society’s job to buy smoke detectors for every individual, then society would – rightly – determine that the cost is not worth the insubstantial benefit.

The only reason most people have smoke detectors is that it is not society’s job to pay for them. The individual does. And the individual does not care that smoke detectors cost $1.2 million per life saved. They only care that the life saved, potentially, is theirs, and that owning the smoke detector that might just save their life does not cost them $1.2 million; it only costs them $19.99.

I am not arguing that preventive services are useless or undesirable. I am simply pointing out that, even when a preventive medical service works exactly as designed, as long as you must pool resources to provide that preventive service to everyone, you will necessarily lose money.

This ought to prove embarrassing to our leaders, who have spent the last few years assuring us otherwise. Indeed, one cannot overemphasize the extent to which they have doggedly insisted that preventive healthcare services are not only cost-effective, but that precisely because of such preventive services (delivered in our new healthcare system’s remarkably efficient manner), we will enjoy tremendous cost savings over the next decades.

That preventive services are simply too expensive is not news to our leaders. They understood it all along. And accordingly, in the Obamacare legislation they took pains to provide themselves with the tools they will need to keep down costs. There is no fighting it.

We can expect to hear repeatedly over the next years that many of the preventive services we’ve all been sold on are, in fact, wasteful and dangerous after all. In some cases, these assertions will be correct. But correct or not, that’s what we will be hearing.

One hopes that the new ACS recommendations on mammography are based purely on an objective assessment of the data. But any professional organization that is as seriously misaligned with the USPSTF as the ACS has been regarding breast cancer screening is asking for it. Whatever the merits of its new recommendations, the ACS has done what it needed to do.

Doctors who value their professional viability will quickly get on board. Women will just have to hope that they fit under the favorable half of the bell-shaped curve.

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  1. DrRich Inactive
    DrRich
    Post author

    Mendel:DrRich, apologies if you thought I was trying to incorrectly impugn you with certain motives or opinion.

    No offense taken

    However, I stand by one point: on a purely economical level, it makes no difference whether preventative care is paid for collectively or individually: if it’s a losing deal it’s a losing deal.

    The problem I see with this is that the idea of “a losing deal” is fundamentally a judgment call. To the collective, a negative mammogram (or worse, a mammogram that leads to a negative biopsy) is certainly a losing deal. An individual woman might also consider it a losing deal. But another woman might consider the whole episode to be a great blessing. Who is right? I think they both are. And while I think it’s perfectly OK for society to agree to pay for mammograms only for women who meet certain criteria, it’s not OK for the authorities to prohibit women outside the designated group from purchasing their own mammograms, if they would find the test reassuring.

    We don’t want to begin insisting that all individual purchases must be designated worthwhile by some group of experts in order to be permissible. Well, you and I don’t, at least.

    • #31
    • October 21, 2015, at 11:05 AM PDT
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  2. H. Noggin Inactive
    H. Noggin

    “As for the women themselves, they can console themselves that their missed opportunity to catch breast cancer at an early stage was ameliorated by the fact that something like 7 or 8 women avoided an unnecessary biopsy. So it’s all good, and their sacrifice to the service of the collective is appreciated.”

    I know this was sarcasm.

    I (and 8 other women) would gladly undergo an “unnecessary” biopsy if it spared another woman breast cancer, or possibly ourselves.

    • #32
    • October 21, 2015, at 12:40 PM PDT
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  3. Vectorman Member
    Vectorman

    H. Noggin:“As for the women themselves, they can console themselves that their missed opportunity to catch breast cancer at an early stage was ameliorated by the fact that something like 7 or 8 women avoided an unnecessary biopsy. So it’s all good, and their sacrifice to the service of the collective is appreciated.”

    I know this was sarcasm.

    I (and 8 other women) would gladly undergo an “unnecessary” biopsy if it spared another woman breast cancer, or possibly ourselves.

    If my wife had to undergo a biopsy, I’d gladly spend $5,000 to find out.

    With that said, I think biopsies would become much less costly, like what has happened with Lasik surgery, etc.

    • #33
    • October 21, 2015, at 12:50 PM PDT
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  4. Could Be Anyone Member
    Could Be Anyone

    I don’t exactly see why there should be mandated or collectivized health care at any level. Let individuals choose for themselves what they desire. Health insurance or none and or only limited insurance for a few different areas, it should be done freely by the will of the individual.

    So far as I know, there is no right to healthcare in human existence. Healthcare is a commodity and massive amounts of government regulation and third party costs have inflated the cost significantly (not even counting the effects of the Federal Reserve). In a mostly free market the price for most treatments/drugs/therapies would be significantly lower than they are today and with lessened degrees of taxation and regulations more charity could be done to aid those in need.

    I fail to see how mandating health coverage and treatment by government fiat (whether agreed upon to the man or not) is a moral solution. There is no moral agency when you are forced to do action x under penalty unless you are a utilitarian and care solely for some end goal. A moral solution is charity by both doctors (provide care) and other individuals (pay for care) providing care without cost for those in need. In that case, moral agents are actually using their free wills (moral agency) to do right. Not to say that doctors are not moral individuals (not giving care is not automatically wrong, there is context to existence) but that charity (freely) for the poor through giving your time and talents is actual moral agency.

    This leftist false dichotomy of either mandated healthcare because you care about the poor or no mandated healthcare therefore you hate the poor needs to be discarded. It is typical leftist pathos/propaganda masquerading as reason.

    • #34
    • October 21, 2015, at 1:43 PM PDT
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  5. MarciN Member
    MarciN

    This is just one more example of the little cuts the healthcare industry is making in healthcare to save money. I’ve been watching this since it passed–ObamaCare is the old managed care on steroids–and I now wish I had written down these little “changes” in preventative care. The upside for the bookkeepers is that women who aren’t diagnosed also won’t be treated.

    But I am also wondering if there is some convincing evidence out there that mammograms are actually causing some cancer.

    I live on Cape Cod where breast cancer rates rose noticeably many years ago. (It was so noticeable that the Silent Spring Foundation opened an office on the Cape. There was some suspicion that it was our Air Force base pollution that was causing it. I don’t think that’s what caused it, but that’s for another day.) The response in the healthcare community was to launch an aggressive mammogram screening program. Then the cancer cases spiked even more dramatically.

    At the time when I investigated mammograms as possibly causing cancer, I found a study in Canada that had determined that x-rays to breast tissue were causing cancer in some women. The mammogram industry was huge, and of course they knocked the Canadian study vigorously.

    Then I started seeing some doctors going in the direction of ultrasound, so I wondered if there was some sort of behind-the-scenes concern.

    I’ve always been curious about this debate.

    • #35
    • October 21, 2015, at 2:02 PM PDT
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  6. DrRich Inactive
    DrRich
    Post author

    H. Noggin:“As for the women themselves, they can console themselves that their missed opportunity to catch breast cancer at an early stage was ameliorated by the fact that something like 7 or 8 women avoided an unnecessary biopsy. So it’s all good, and their sacrifice to the service of the collective is appreciated.”

    I know this was sarcasm.

    H. Noggin,

    Not sarcasm, exactly. I was trying to state, as accurately as I could, how Progressives might justify their position, should they ever actually have to admit what their position really is.

    • #36
    • October 21, 2015, at 2:02 PM PDT
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  7. DrRich Inactive
    DrRich
    Post author

    MarciN:But I am also wondering if there is some convincing evidence out there that mammograms are actually causing some cancer.

    MarciN,

    There is always some increase in cancer risk with the use of any radiation, even x-rays. However, from studies that have looked at this it appears that the lifetime increase in cancer risk due to routine mammography, for most women, is immeasurably low. This calculus changes however for women with BRCA1 or BRCA2 mutations. These mutations are associated with an impaired ability to repair damage from radiation, and their risk of radiation-induced breast cancer probably is measurably higher with repeated mammography.

    It’s one of the things that makes it difficult for women with BRCA1 or BRCA2 mutations, and their doctors, to decide on an optimal course of action.

    • #37
    • October 21, 2015, at 2:14 PM PDT
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  8. H. Noggin Inactive
    H. Noggin

    “Not sarcasm, exactly. I was trying to state, as accurately as I could, how Progressives might justify their position, should they ever actually have to admit what their position really is.”

    Dr. Rich,
    I guess the way progressives justify most things demonstrates a way of thinking that I find ridiculous and therefore, not serious. Thanks for clarifying.

    • #38
    • October 21, 2015, at 2:38 PM PDT
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  9. Bryan G. Stephens Thatcher
    Bryan G. StephensJoined in the first year of Ricochet Ricochet Charter Member

    DrRich:

    Bryan G. Stephens:If we are going to have government $ in healthcare, I vote for a pure voucher program. Phase out Medicaid and Medicare, and phase in vouchers.

    Bryan,

    Vouchers in healthcare, vouchers in public education, and for that matter, capitalism itself, all fly in the face of the fundamental Progressive truth, to wit: establishing the perfect society will require the enlightened few to direct the actions, beliefs and behaviors of the masses, and therefore will utterly require the stifling of individual prerogatives.

    No go on vouchers. Sorry.

    And yet, gun control is losing ground.

    And yet, the greatest military in the world failed to hold on to America.

    • #39
    • October 21, 2015, at 2:44 PM PDT
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  10. Tom Meyer, Common Citizen Contributor
    Tom Meyer, Common Citizen

    Mendel:However, I stand by one point: on a purely economical level, it makes no difference whether preventative care is paid for collectively or individually: if it’s a losing deal it’s a losing deal. This is true for any type of insurance or risk-based purchase. However, it is precisely for that reason that we should leave the decision to individuals.

    I think Mendel is correct that there are two distinct-if-connected questions:

    1. Economically, is preventative medicine — or, better, any particular preventative medicine — actually cost effective in the context of a system that involves pooling? The answer appears to be generally not.
    2. Is this issue compounded by — and particularly ill-suited to — government pooling systems in comparison to ones that are more free-market orientated? Seems like a definitely.
    • #40
    • October 21, 2015, at 3:26 PM PDT
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  11. Tom Meyer, Common Citizen Contributor
    Tom Meyer, Common Citizen

    Mendel: We all despise the notion of government deciding when we should die, but how would it work if everyone paid for their own healthcare? Many, probably a majority, would die younger than they now do with Medicare. There is a real moral dilemma here. We don’t want to let people die because they can’t afford something. We don’t want government to overpay for healthcare people don’t need. Yet we also don’t want government to decide when people die.

    This is why I found the “rationing” and “death panels” arguments against Obamacare misguided. Again, any system based on pooling will have to employ some kinds of price controls that could accurately go by that name. That stinks, but it’s reality.

    The better point is that the rationing will be more rational (less irrational?) through pricing controls than political ones.

    • #41
    • October 21, 2015, at 3:32 PM PDT
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  12. MarciN Member
    MarciN

    DrRich:

    MarciN:But I am also wondering if there is some convincing evidence out there that mammograms are actually causing some cancer.

    MarciN,

    There is always some increase in cancer risk with the use of any radiation, even x-rays. However, from studies that have looked at this it appears that the lifetime increase in cancer risk due to routine mammography, for most women, is immeasurably low. This calculus changes however for women with BRCA1 or BRCA2 mutations. These mutations are associated with an impaired ability to repair damage from radiation, and their risk of radiation-induced breast cancer probably is measurably higher with repeated mammography.

    Thank you. :)

    • #42
    • October 21, 2015, at 4:13 PM PDT
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  13. iWe Reagan
    iWeJoined in the first year of Ricochet Ricochet Charter Member

    Tom Meyer, Ed.: This is why I found the “rationing” and “death panels” arguments against Obamacare misguided. Again, any system based on pooling will have to employ some kinds of price controls that could accurately go by that name. That stinks, but it’s reality.

    Those of us screaming about Death Panels were making a key point: That rationing of care is inevitable – but with Obamacare, the decision will not be up to the patient, or the doctor. Obamacare is the acceptance that the federal equivalent of the DMV gets to decide and impose the limits of care.

    • #43
    • October 21, 2015, at 4:41 PM PDT
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  14. DrRich Inactive
    DrRich
    Post author

    Tom Meyer, Ed.:

    any system based on pooling will have to employ some kinds of price controls that could accurately go by that name. That stinks, but it’s reality.

    Tom,

    Agreed.

    Healthcare rationing is to intentionally withhold at least some available healthcare services from at least some of the people who might benefit from it.

    Under this definition, we all must agree (as you do) that some degree of rationing will certainly be necessary under any system where costs are pooled. Thus, rationing should not be a dirty word. Openly discussing the necessary rationing would at least give us a fighting chance to figure out how to do it with the least amount of damage possible.

    The real trouble comes when we deny that any rationing is necessary, and insist that even to talk about rationing is immoral. This attitude leaves us no choice but to conduct the unavoidable rationing secretly, deceptively, covertly, by whatever means we think we can get away with.

    Ironically, covert rationing is supremely wasteful. For, in order to hide the rationing it is imperative to obfuscate, misdirect, complicate, and do whatever else we must to convince everyone – often including ourselves – that whatever it is we’re doing, it’s not rationing. That is, we’ve got to create an environment of complexity and opacity in which we can get away with it. (continued. . .)

    • #44
    • October 21, 2015, at 4:51 PM PDT
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  15. DrRich Inactive
    DrRich
    Post author

    (. . .continued from previous comment)

    Covert rationing absolutely requires opaque processes and procedures, superfluous complexity, bizarre incentives, Byzantine regulations which are arbitrarily enforced or ignored in various times and places, astoundingly wasteful transactions, and the diversion of healthcare dollars to a complex host of non-healthcare ends, such as commissions, study groups and panels, various czars of this and that, ever-expanding layers of government bureaucracies, and the establishment of other massive bureaucracies within the healthcare system whose purpose is to defend against or manipulate those aggressive government bureaucracies.

    Covert rationing, by its very nature, demands and creates tremendous waste within our healthcare system, and therefore costs us far more money than it can ever save us.

    Under any collective payment system, denying the need to ration utterly precludes any sort of equitable healthcare system. I and many others have suggested healthcare systems where the rationing can be minimized and conducted openly and as equitably as possible. But no real solution to our healthcare mess is possible until we admit that rationing is unavoidable.

    The more currency our population gives to infantile socialist desires, of course, the less likely this is to happen.

    • #45
    • October 21, 2015, at 4:51 PM PDT
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