OP-ED

Your Money or Your Wife

Talk about perfect timing.  Just as the last “death panel” falsettos fade into the droning no-government-  takeover chorus, along come those “faceless government bureaucrats” from the U.S. Preventative Services Task Force to stop the music in the nation’s busy and profitable mammography suites.

No more breast self-exams or mammograms for low-risk women under 50; mammograms only every other year after the age of 50; nothing for any woman over 74.  That was the thunderclap pronouncement from the acrobatically acronymic USPSTF, the dreaded “they” from the gub’mint that has the folks at Fox in full fulmination.

While the House and Senate grind their way through a few thousand pages of legislation and one more battle in the perennial abortion rights Holy War, this abrupt about-face in cancer screening is all people want to talk about, when we’re talking about health reform, in corporate strategy meetings.  And the mix of incredulousness and anxiety in their voices speak volumes: this startling news from the health care technocracy does not affect their business; rather, it seems profoundly and directly to affect them personally, men and women alike.

Why so sudden and radical a reversal, they all want to know, in the war against cancer we have been winning for decades?  And so I, swallowing hard, explain that the very smart people on HHS’ AHRQ’s USPSTF have discovered that all the effort and money dedicated to breast cancer screening for women under 50 actually saves only one life for every 1,904 women screened – while generating too many false positives, hundreds of unnecessary biopsies, and excessive anxiety.

It’s a big waste of money, “they” now tell us, and that certainly works for me, I say, swallowing hard again.  I’m a male medical economist, after all, a hard-headed advocate of hard numbers, data-driven medicine, solid evidence, and efficiency, and I despise waste almost as much as I despise cancer itself.

Unless, of course, that one case in 1,904 happens to be my wife.  Or my sister.  Or my daughter.  Would I, looking at that same study data from across her fresh grave, countenance the inconvenience and cost for those other 1,903 women?  You’re damn right I would.

Not unlike the health insurance executives infamous for denying experimental treatment for everyone in their plans except their own family members, I know what I know is best for the group, for the public health, and for society – and to hell with that.  What is best for the group has nothing to do with what is best for my best friend, even though she is low-risk and 46 years old.  She should be screened, every year; and if her commercial health plan now has government-sanctioned cover fire not to pay for it, I will.  Early detection is the single most important and durable factor in individual cancer survival, the epidemiology and economics of the group be damned.

You Are a Study Population of One

As for the incredulous and anxious colleagues who keep asking me to interpret the new guidelines, this is not an academic discussion for me.  I have lost two friends, so far, to breast cancer, one on the eve of her 40th birthday.  I have “raced for the cure.”  And I have wept and prayed alongside nine other friends who, so far, have managed to survive the disease, and the horrific brutality of its treatment.  (If the epidemiology of my social circle seems jinxed for a 47-year-old, know that its epicenter is a synagogue; when it comes to breast cancer, Jews really are the chosen people.)  Truth to tell, I of course despise cancer more than I despise waste, to the point where I cannot think about the subject rationally, and I don’t think I’m an anomaly among even the most educated health policy wonks.

No, this is not a reasonable nor responsible position to take on this incendiary subject.  But I suspect it is the position that most otherwise reasonable and responsible Americans would take.  For proof, we need look no further than the nearest NICU waiting room.  Our cultural belief in the sacrosanct, unlimited dollar-value of an individual life – oddly American and manifest no more plainly than in our bloated, screeching tort system – explains much about why U.S. health care costs what it does.

It also provides a picture-window into how most Americans confront the health care system today, and will continue to confront it tomorrow, nudged along either by piecemeal health services research or kicked down the road by concerted reform, with their employer’s money or with their own.  If those faceless government bureaucrats say “no” – not unlike the faceless bureaucrats behind the managed care curtain have been trying to do for 20 years – then we’ll just buy what we want with our own money.  This triangulated market dynamic is precisely how we ended up with “flexible spending accounts” and multi-tier drug formularies.

Of course, American women may not swallow the breast cancer screening revisionism as easily as we have all swallowed the bitter pills of aggressive pharmacy benefit management.   The “women’s health amendment” rammed through the Senate right after the USPSTF announcement is Exhibit A of the intense fear that breast cancer strikes in the body politic.  But that amendment, like mostly symbolic abortion coverage and the dreaded public option, is one more trading card in the most critical Congressional negotiation since the 1960s, so it is best not to count on it mitigating the effects of the new guidelines.

More likely, we should consider the new guidelines as one more big step down the path to a bifurcated health care system of medically necessary versus psychologically soothing, of what gets covered versus what gets turned into a cash business.  Time, legislation and benefit design will tell.

Retail Radiology

In the meanwhile, the radiologists of America can relax: the new guidelines will not be followed by most women and most doctors.  If the technocracy wins out over the politicians, mammograms for low-risk women under 50 will simply migrate into the “self-pay” category.

For proof, we need look no further than the success of the pharmaceutical industry at selling drugs that have been booted off formularies and out of benefit plans altogether.  Mammograms for women in their 40s will join Botox, massage therapy, executive physicals, faith healing, herbal remedies, and all the other medical confections gobbled up by a neurotic, narcissistic, superstitious society addicted to medical care.  As Voltaire once noted, “medicine’s role is to entertain us while nature takes it course.”

And that’s the junk, not a serious procedure that, until a few weeks ago, was a cornerstone of breast cancer prevention for women all the way down into their 30s.  Ample conference speaking experience has taught me that if you want to turn a roomful of noisy, fidgeting, Blackberrying people stone cold quiet, just say “breast cancer.”

This may have more to do with our complex collective angst about breasts, sex, and motherhood, than with our baseline angst about cancer, disability and death.  As most heterosexual males discover, often abruptly at a certain point in early adolescence, there is something quite remarkable about the female breast. With the possible exception of the heart, the breast is more freighted with mystery and meaning than any other feature of human anatomy.  Associated unconsciously with our earliest and most nurturing (and paralyzing) memories of sustenance versus starvation – and associated consciously with our desirability (or desire), gender identification, and self-worth (or pride in our mate’s projected worth) – the female breast is electrified with pre-verbal psychological energy.  If this were not true, plastic surgery would be a radically smaller and less lucrative business, and we would not recognize the visual landscape of the typical retail newsstand, where today breasts dominate not only shrink-wrapped porn, and not only music, entertainment, and men’s lifestyle magazines, but many of the women’s lifestyle magazines as well.  This is the wellspring of the fury over the findings, the next-day “women’s health amendment,” and the outsized shock and curiosity by so many of my otherwise level-headed health care business colleagues.

If the women’s health amendment is traded away for a few more votes in the House, the new guidelines will stand; and consistent with what the crackpots fear most about “death panels,” the findings of the USPSTF will drive what is and isn’t covered by a standardized, subsidized, reform-hatched health plan – whether administered by an “exchange,” a private plan, a non-profit co-op, the OPM’s FEHBP, or Halliburton.

As mentioned earlier, those findings will also quickly find their way into commercial health insurance plans.  “Consumer-driven health care” – roughly translated as “consumers pay more for health care” – has been highly effective at shifting demonstrably “wasteful” medical spending (e.g., the high marginal costs for only marginally better medications) from the employer/health insurer risk pool to the individual’s wallet, HRA, FSA, or HSA.  And if it were not for the tax-advantaged status of all that spending, we could easily write it off as no-harm/no-foul to the macro-economy.

But radiology businesses learned years ago to direct-bill patients for procedures they did not need, with the introduction of “full body scans” marketed to otherwise healthy people, or what I like to refer to as “recreational MRIs.”  The business strategies for marketing newly “unnecessary” mammograms will surely be no different.

Is This Any Way to Run a
Government Conspiracy?

Beyond the inevitable market durability of a now discredited procedure for women under 50, there is something quite odd about the timing of the new breast cancer screening guidelines, given the fury the news was certain to unleash.  If nothing else, choosing to open this Pandora’s box of empiricism versus emotion just as Congress is preparing its final push on health reform is proof positive that there is certainly no orchestrated conspiracy inside the Beltway to lull us into accepting a government takeover of health care.  It would seem designed, actually, to have just the opposite effect, stirring up even the most ardent supporters of reform over what those “faceless government bureaucrats” want to take away from us first.

Better still, if you were a left-wing conspiracy theorist, you could make a good case that this whole thing is the work of somebody on the far right: they set up the USPSTF to announce these guidelines now, just in time to enrage the country at the health care technocracy and foil the Democrats’ grand designs.  Get the federal government to un-do a generation’s vaguely comforting beliefs about breast cancer prevention at the precise moment that half of Congress is trying to convince the other half that health care is long overdue for some central planning, and see what happens.

Back in the real world, the announcement is also perfectly timed for open enrollment season for employee benefits and its sundry financial planning tasks.  The smart money would bet that smart women in their 40s are Googling the cost of a mammogram and putting about that much extra into their health care spending accounts.

J.D. Kleinke is a medical economist, author, and health information industry pioneer.  He has been instrumental in the creation of four health care information organizations; served on several public and privately-held health care information company boards; and written about health care business policy for The Wall Street Journal. His work has also appeared in JAMA, Barron’s, the British Medical Journal, Modern Healthcare, and numerous other publications.  His books includeBleeding Edge: The Business of Health Care in the New Century (1998), Oxymorons: The Myth of a U.S. Health Care System (2001), and Catching Babies, a novel about the training of OB/GYNs, which will be published next year.

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stellaRoss D. Martin, MD, MHAfamilial predisposition to breast cancerNateApril Recent comment authors
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stella
Guest

As a UK resident, I find the US health system shocking. I was watching the “Sick” by MIchael Moore, that reveals how the US health system is based around money and insurance companies’ interest. As someone who enjoys free health care (sorry not trying to boast here) it is quite surprising that the worlds richest nation would put it’s people at such risks for money only.

J.D. Kleinke
Guest

Thanks, Ross – you’re making a better and more eloquent case than I did on this controversial topic, but a case for society, not for individuals. But I do appreciate your own wife’s story, and the important lessons it brings. I agree completely that the best and wisest use of our resources should be spent on prevention and wellness, not flogging diseases – many of which can be avoided through better living without chemistry – but I don’t think this is an either/or choice. I believe we can and should have both, and I also believe we can afford both.… Read more »

Ross D. Martin, MD, MHA
Guest

As usual, JD, an eloquent and fearless commentary on a hot-button issue. My counterpoint, filled with the same passion but leading to a different conclusion, is best illustrated by recounting a conversation with my wife from a few years ago. Kym is a 26-year Hodgkin’s Lymphoma survivor and pursues health with the zeal of someone who will never go down without a fight. She reads everything she can get her hands on about fitness and nutrition – focusing on holistic approaches but also checking every box she can to ensure that anything penetrating this primary line of defense is caught… Read more »

Anonymous
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Anonymous

Not sure about the NY insurer #s since I didn’t read the article, but if the terminology being used is accruate this 18.7% is the villified, misunderstood medical loss ratio, or the revenue that is left over after paying medical and pharmacy claims. These net revenues pay people’s salaries, pay for the cost of processing claims, capital investmants, and all that SG&A accounting stuff. The low single digit profits (probably around 4% for the industry) is what’s left over after all that. The fact that it (this 18.7%, the inverse of the loss ratio) went up 25% is probably due… Read more »

familial predisposition to breast cancer
Guest

Breast cancer is the most common type of cancer in women around the globe. It comes as no surprise, that, everybody seems to know at least one woman who has breast cancer or has been challenged by it in the past. It has been estimated about 1 out of every 7 women in North America will be affected by this deadly disease in a 90-year life span. Have it ever occurred to you that for simply being a woman and getting older, you too, can be affected by the disease during your lifetime? However, it is possible to reduce the… Read more »

Barry Carol
Guest
Barry Carol

Margalit – I would have to defer to someone who knows more about health insurance company subsidiary level accounting than I do, but I think there are two issues that need to be better understood. First, did reserves have to be built in prior years because claims were higher than budgeted? Second, how large are the expenses at the parent level? It could be that subsidiary level gross profits are comparable to the contribution to profit from a single successful store in a large chain like Wal-Mart or Walgreen. At the store level, gross profit might be 25% of sales.… Read more »

Margalit Gur-Arie
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Margalit Gur-Arie

Barry,
I find it fascinating that these NY insurers have a 25% larger excess from premiums collected in 2008 than they had in 2007, and that for one of the payers it constitutes 18.7% of the total premiums collected. I’m not sure how this sits with the much advertised single digits of net profit.
How much are these people really paying for medical care if they have 18.7% of collections left over after all medical claims are paid and all SG&A is taken care of?

Barry Carol
Guest
Barry Carol

Margalit – The question implicit in your first link is a bit away from my expertise but I’ll try to answer it as best I can anyway. Insurers are regulated at the state level. Among the factors that regulators control are the amount of reserves each insurer that operates in the state must maintain and the coverage benefits they must offer. The large national health insurers have numerous subsidiaries. Wellpoint, for example, owns 14 of the 39 Blues plans. Capital requirements vary by state and are intended to ensure that claims will be paid as they are incurred. Most insurers… Read more »

rbar
Guest
rbar

“Somehow it seems to me, for example, that whether a woman of any age should or should not have a mammogram at a particular time, is a decision that needs to be made by the woman and her doctor in light of all the available guide lines. Physicians do not usually profit from ordering mammograms and women do not enjoy having them (understatement). So what exactly is the point of creating more rules and regulations and adding to billing complexity and bureaucracy which will eventually cost as much as staying out of the doctor’s exam room?” Margalit, I am sorry,… Read more »

Margalit Gur-Arie
Guest
Margalit Gur-Arie

Dr. Kirsch, it would be foolish to completely disregard cost of care, of course. However, cost of care is a continuum and so is quality of outcomes, which makes it very hard to decide on the optimal equation. I just happen to think that the decision should be left to patients and doctors as long as there is no irrefutable evidence that the particular treatment is harmful or exactly equivalent to a much lower cost option (i.e generics). Somehow it seems to me, for example, that whether a woman of any age should or should not have a mammogram at… Read more »

Michael Kirsch, M.D.
Guest

Margalit, when I am advising an individual patient in my office, I am not considering the costs of the recommenddation, although the patient may do so, particulary if it is not a covered benefit. From a global perspective, cost must be included in the process. See this link to see what happens when cost of care is ignored. Ilearned about the fiasco of this drug last week. Absurd! http://bit.ly/5XxRWK

Peter
Guest
Peter

“forecably cutting them off” Expand that accusation Nate. My experience in Canada shows this is NOT how the single-pay system works and you would be astounded how well the elderly are cared for there. The healthcare of my aging mother there was nothing but patient/doctor/relative contolled. She was never “cut off”, and I, as her legal guardian, had the choice at her end of life to control how SHE wanted her medical issues handled through her living will. “Eliminating lifetime maximums and capping annual out of pocket” Your preferred method of, “cutting them off” even when not at end of… Read more »

Nate
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Nate

rbar raises an interesting fact. Our problem is the 20% of the population that consume 80% of the care. In every other country they control this by rationing the care those individuals recieve, forecably cutting them off. What do the liberals in America propose…. Eliminating lifetime maximums and capping annual out of pocket. Yes American liberals are that stupid. The one small price control we have left and they want to outlaw it. I would argue with anyone the reason we spend twice as much of GDP as anyone else is 100% becuase our liberals are twice the morons as… Read more »

April
Guest

Most breast cancer patients have mutated genes which aggravates the situation and which have been found to be a contributing factor in people with cancer.
But breast cancer can be prevented. A healthy lifestyle like not smoking or not drinking, regular exercies and having the right weight can contribute to lowering the risks of having breast cancer.
Studies show that women who breastfeed for several months get the benefit of reducing their breast cancer risk. The body has natural ways of healing, if only we choose a healthy lifestyle.

Barry Carol
Guest
Barry Carol

Margalit – I think it’s extremely difficult if not impossible to make “apples to apples” comparisons with respect to utilization of hospitals and physician services in the U.S. vs. other developed countries. You may find, for example, that there may actually be more inpatient hospital bed days per thousand of population in other countries than in the U.S. though I don’t know for sure. What I do know is that hospitalized patients in the U.S. have much more done to them from testing to drugs to surgeries to use of intensive care beds. Care that may be provided in a… Read more »