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Monday, May 9, 2011

Lifeline Screening, prevention and early detection of disease

Most of what we think of as preventive medicine is actually not that at all. Mammograms, pap smears, colonoscopies, all of these are actually early detection of disease. Abnormal results on any of these tests prompts more testing and sometimes treatment, which may or may not result in better health or a delay in becoming ill or dying.  True prevention of disease would include healthy diet, exercise, accident prevention, safe sex and adequate birth control. These are the kinds of things that truly keep people from getting sick, but most of these are not truly in the scope of care provided by physicians.

Today I got a letter in the mail from a company called Life Line Screening, inviting me to "participate in a simple potentially lifesaving screening to assess...risk for stroke, abdominal aortic aneurysms and other vascular diseases."  There will be a bunch of ultrasound technicians in a nearby community center who will be eager to check my blood vessels for narrowings, and my abdominal aorta for widening, which might indicate an aneurysm.  Any of these tests would cost me $60, but I can get all of them, 5 tests for $159. The tests will be run by technicians and read by qualified physicians and I will get my results in a few weeks. As far as the money costs, this is not at all a bad deal.  Any of these tests if done in our hospital would cost much more than the total cost of $159, though I would receive my results more quickly and the level of detail would be considerably higher. The only hitch is that I don't actually need any of these tests, and it is likely that my health related anxiety will be significantly higher than my baseline as I wait for the results.

The US funds a task force to determine which tests contribute to lengthening life and improving its quality, called the United States Preventive Services Task Force (USPSTF.) This group uses the data from many clinical trials to determine who should get which testing and at what frequency in order to maximize health. It turns out that routine screening for breast cancer before the age of 40 (or 50 in the case of low risk women) probably causes more harm than good. Prostate cancer screening for men with no symptoms is also in this category. Screening for prostate cancer in a man who is over the age of 75 is definitely a bad idea, leading to more, not less death and disability than no screening. Vascular procedures such as done by Life Line Screening are mostly not helpful in making us healthier, with a few exceptions and a handful of caveats.

Screening for abdominal aortic aneurysms is definitely a good idea in men over the age of 65 who have ever smoked. This is widely enough accepted that Medicare now pays for it without any co-pay. So if I were the right person to get this test, I would not have to pay anything for it, and my doctor could order it from any hospital that I preferred. Screening for atrial fibrillation and peripheral arterial disease should be a normal part of any physical exam, and ultrasound testing for these things may not add any significant accuracy. Checking the carotid arteries for narrowing is not shown to reduce the incidence of stroke, though it can raise a person's consciousness of the need to reduce vascular risk. The final test offered by Life Line is an ultrasound of the bones of the heel to check for osteoporosis, but that is a really poor test for detecting the strength of important bones, and with expanded insurance coverage for preventive services, most insurances, and definitely Medicare, cover a better test, called the DEXA scan, without any co-pay in appropriate patients.

But all this said, I am not entirely against Life Line screening.  I find that the act of scheduling this testing, showing up, and receiving the results in the mail is an important first step for patients that heads them in the direction of taking better care of their health. The community event of having this company come to a church or gymnasium brings people together to talk about health and focus on what might be ways they can postpone or prevent actual disease. For patients who have no regular doctor and receive no medical or prevention advice, either because of lack of money or of motivation, an abnormal result on a screening test such as this may be a very important piece of information.

Another issue that is very interesting here is that pretty sophisticated testing can be provided much less expensively than in hospitals or doctors' offices. How can it be that this company can do an ultrasound of my carotid arteries for less than 1/10th the cost that my local hospital would charge me? The answer gets back to two major factors that increase cost of American health care: liability (the cost of malpractice suits) and third party payment systems (health insurance). Because the company that does this screening does not bill insurance companies and because patients pay up-front for their care, the care is inexpensive. An ultrasound machine and the services of a technician are not very expensive, and the physicians that read the exams can do so very quickly since the scope of the exams is limited. The process does not involve a doctor-patient relationship and refers all patients back to their primary care physician, so they are not liable to the kinds of lawsuits that drive up physicians' fees. The overwhelming popularity of Lifeline Screening and programs like it demonstrate that Americans are very motivated to receive medical care that is slightly substandard if the cost is reasonable. This is not an option being offered to patients by our present health care system. When the American consumer wanted an affordable automobile, the model T was created. In medical care, we seem only to be able to come up with a newer and fancier Mercedes Benz.

Bottom line? If a person has a good doctor, he or she doesn't need a set of 5 Life Line Screening tests. There is no evidence to suggest that getting these done in addition to regular physicians' care will lengthen life or reduce disability. The fact that many of us do not have regular physicians' care due to the cost and difficulty of even having access to a doctor ensures that programs like this will continue to be popular and profitable.

1 comment:

Anonymous said...

Thank you for this well-written and very informative post. For someone like me, with a non-medical background, it's very helpful to hear the details you've provided about these tests. p.s. I'm posting as Anonymous only because I don't have any of those other accounts. I do have a Disqus account, but that's not available in your drop-down list.