The insurance industry is fundamentally focused on ensuring that cost
outlays for medical care are less than the future premiums to be
received resulting from increased health and life spans resulting from
the medical care. Therefore, a cost/benefit approach is the viewpoint
the insurance industry would take.
Therefore, for a given diagnosis, an insurance company would want to
ascertain the costs and benefits of having a scan conducted. The
relevant criteria include the likelihood the diagnosis without a scan
is correct, the likely cost of the initial diagnosis is incorrect, the
cost of the treatment for the diagnosis, the likelihood of adverse
complications from the scan, the chance of a false positive resulting
from the scan, and the chance that the diagnosis will result in
medical complications. CT scans are of particular concern because it
is increasingly recognized that any dosage of radiation is potentially
harmful, and CT scans impart a significant amount of radiation to a
patient ("X-Rays May Raise Cancer Risk" by Miranda Hitti, Fox News
(June 30, 2005) http://www.foxnews.com/story/0,2933,161268,00.html).
In his book "Calculated Risks,"
(http://ipac.ci.irving.tx.us/ipac20/ipac.jsp?session=H120326318FT8.13913&profile=c1&uri=full%3D3100001%40%21468730%40%210&ri=2&&aspect=alpha&menu=search&ri=2&view=DBCHAPTER.XML&aspect=alpha&menu=search&source=172.26.8.63@!horizon)
Gerd Gigerenzer examines the costs and benefits associated with
mammography. As of 2002, the studies he reviewed indicated that there
were insufficient benefits associated with the costs of mammography.
A very high rate of false positives existed, many breast abnormalities
do not go on to become life-threatening, the chance of breast cancer
development because of radiation from the mammography is significant,
and the tests are expensive. Although very few women benefit from the
testing, and many women undergo unnecessary surgeries and experience
unneeded anxiety as a result of false positives, ordinary people and
even doctors have been convinced that regular mammography is essential
for good health. Public pressure has resulted in insurance companies
having to cover mammographies even though money could be better spent
on cardiovascular disease screening for women, which kills far more
women than does breast cancer. Furthermore, many doctors have
invested in screening equipment, which encourages them to test as many
patients as possible to pay for it and maximize their profits. The
same issues are becoming increasingly prevalent with respect to MRI
and CT scan usage.
A fair method for controlling costs to society as a whole would be to
limit the usage of MRI and CT scans to those cases where they can
impart sufficient benefit to offset both the financial expense
associated with the scans and costs associated with adverse patient
events and false positives. Tests that are being done when the
diagnosis is essentially certain simply to protect the physician from
malpractice claims are wasteful. Tests that are being done when there
is no treatment available even if the diagnosis is confirmed are not
useful. Tests that are being done when the treatment for the
diagnosis is inexpensive and low risk to the patient are of
questionable benefit.
The most cost effective tests are those where either considerable
uncertainty exists regarding the diagnosis and proper treatment or the
treatment associated with the initial diagnosis is very expensive
and/or risky. In these cases, if a scan can greatly reduce false
positives in the initial diagnosis while not creating a large number
of new false positives, thereby eliminating the need for expensive
and/or risky treatments, then the scan is certainly justified from an
insurance company's perspective.
The best way to go about this would be to conduct studies such as
those cited by Gerd Gigerenzer for mammography for the most common
conditions where MRI and CT scans are used. Using these, the public,
doctors, and insurance companies could make informed decisions about
which diagnoses should be confirmed through the use of MRI and CT
scans and which should be treated without them. As Gerd Gigerenzer
demonstrates in his book through many studies he has conducted on
physicians and the general public, considerable education needs to
take place about statistics in general and the cost to treat one
person using these techniques if this is to be successful, though.
Unfortunately, patients and doctors frequently believe that tests are
infallible, harmless, and always useful when they almost never have
any of these characteristics absolutely. Most individuals believe
they will be the one out of 1000 that will benefit if everyone is
screened when it is far more likely that they will be one of the 999
out of a thousand that receive no benefit and are even more likely to
be one of the 10 or 20 out of a thousand that receive a false positive
or are harmed by the test. Many patients also have difficulty
understanding that they can have a variety of very slow growing
cancers that can be detected by the scans but, even if they are left
alone, are unlikely to pose a significant medical risk. Many people
have prostate cancer, for example, but are killed by something else.
Particularly since there is no definitive effective treatment for
prostate cancer, existing tests have high risks of false positives and
false negatives, and existing treatments frequently have severe side
effects such as impotence and incontinence, widespread screening for
prostate cancer is questionable.
While a cost/benefit approach is the most equitable one for society as
a whole, and is feasible if the appropriate studies are done, the
public's innumeracy will make implementing such an approach very
difficult. It is clear that society cannot afford to continue to
excessively use tests when they do not deliver benefits. For example,
medical spending in the United States is the highest in the world, but
the United States ranks only 37 of 191 countries in terms of medical
outcomes ("WORLD HEALTH ORGANIZATION
ASSESSES THE WORLD'S HEALTH SYSTEMS" World Health Organization (June
21, 2000) http://www.who.int/inf-pr-2000/en/pr2000-44.html). Medicare
is starting to address this issue by providing incentive payments for
health care providers that have better medical outcomes for certain
conditions, thereby incentivizing effective treatment rather than just
treatment regardless of benefit. Given that, "the least expensive 70%
of patients account for 10% of the expenditures; and the most
expensive 1% of patients account for 30% of expenditures" in a given
year ("Managing High-Risk, High-Cost Patients: The Southern California
Kaiser Permanente Experience in the Medicare ESRD Demonstration
Project" by Dr. Peter Crooks, The Permanente Journal (Spring 2005)
http://xnet.kp.org/permanentejournal/spring05/highrisk.html), it is
clear that there are many opportunities to reduce the health care
spending of society as a whole without affecting the majority of
people. Limiting expensive, questionable testing to those who can
afford it would be another way to control society's expenses in the
form of health insurance premiums, although it may not be viewed as
being fair.
Sincerely,
Wonko |
