It's been a big day for screening discussions. Screening: good! No--screening bad! Depends on who's doing the evaluations of risk/benefit, it seems.
The Centers for Medicare and Medicaid (CMS) national coverage determination panel ruled that annual screening for lung cancer by low-dose CT scan for high-risk individuals would not be covered. The reasoning behind this decision was somewhat convoluted, but in summary amounted to this: Annual low-dose CT lung cancer screening for high-risk individuals doesn't have enough evidence for benefit over harms to be covered by Medicare, the advisory panel concluded. Key concerns were the high false-positive rate of CT screening, indication creep outside of the intended screening population, inability to assure quality scans with low radiation dose, and consistent interpretation and diagnostic workup in routine practice.
If we don t do it right now, it s a genie that won t be able to be stuffed back in the bottle, Peter Bach, MD, of Memorial Sloan-Kettering Cancer Center in New York City argued at the panel meeting, according to an article in MedPage Today.
One of the main concerns cited was generalizability of the pivotal National Lung Screening Trial (NLST) upon which the U.S. Preventive Services Task Force (USPSTF) grade B recommendation was based and in turn prompted the national coverage determination. The CMS panel noted that, in the NLST, only a quarter of the trial population was 65 or older and none were enrolled past age 74. (ACSH Dispatch discussed that trial last year).
It was a big day for screening discussions: Dr. H. Gilbert Welch, one of the nation s leading experts on the pros and cons of screening, wrote an op-ed in the NYTimes entitled The Problem With Free Health Care. He points out the paradoxical consequences of the Affordable Care Act s focus on screening access as part of its prevention mantra: if a woman wants to get a routine screening mammogram, she can get it free of charge although studies (including several by Dr. Welch) have shown that the benefits for long-term health from such tests are vastly outweighed by its harms. On the other hand, if a woman feels a breast lump, and heads for the radiologists office for a diagnostic mammogram, she is no longer entitled to free care although this type of test is absolutely necessary and clearly beneficial for health. BUT since it s no longer a screening test, but a diagnostic, she must pay for it.
Dr. Welch professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and an author of Overdiagnosed: Making People Sick in the Pursuit of Health also points out similar paradoxes and ironies in the financial impacts of testing for colon cancer (suffice it to say that perverse incentives are easily found here as well, but you ve got to read it to believe it) and other ailments.
ACSH s Dr. Gil Ross had this comment: I guess whenever a healthcare system as vast as ours is overhauled to the extent that the ACA- Obamacare has done, some perturbations are going to be felt that are neither just nor fair, nor even rational. The bizarre disincentives described by Dr. Welch fit in that category.
As Dr. Welch says, Now that it s clear that Obamacare is here to stay, its supporters should focus on making the program better. Fixes are not a sign of weakness. They are a sign of responsiveness and of good management. And the Affordable Care Act does have its flaws. Here s a big [flaw]: It favors screening over diagnosis ¦.I wish money wasn t such a powerful incentive in medical care. But the economists are right: Incentives matter. Right now they favor lower risk patients (those being screened) over higher risk ones (those with signs and symptoms)....They also encourage a feeding frenzy among providers to recategorize diagnostic testing as screening. Free screenings were seen as a way to get people through the door and ideally to find and address problems before they become more dangerous and expensive. But in practice, it may not work this way. Some hospitals offer free screening knowing full well that the costs will be more than made up for by all the subsequent services required. More testing, false alarms and overdiagnosis are all part of screening. And if you make it free, patients are less likely to give proper consideration to these potential harms not to mention the potential for a lot of out-of-pocket costs down the line. Here s the fix: Eliminate the incentive mismatch between screening and diagnosis. Treat them equally.
Ross again: As for that CMS decision well, we are skeptical about screenings, as our loyal Disptach readers know. But this seems to me to be a mistake: high-risk patients, smokers, have a significantly higher risk of lung cancer, and the NLST clearly showed a major survival benefit amongst those screened. If I were in practice now, I d urge my patients with heavy smoking histories to get that CT scan, whatever its cost.