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The 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:
- The preventive measure itself costs money.
- The preventive measure may not be very effective.
- 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.
- “Early detection” of any medical condition often detects “occult” disease that might never become manifest.
- Treating the diagnosed — and often occult — medical condition often costs a great deal and produces expensive complications. And it is often ineffective.
- 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.
- 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.
- 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.Published in