Scanning: Who Pays?

A fellow journalist asked for information on screening scans, CT, MRI, Ultrasound exams, etc., like those increasingly being offered as ways to look for heart disease, cancer, and other diseases, without the risks of some other tests.

She wanted to know how much do they cost and who pays?

Well, leaving aside the serious issues of the thin or nonexistent evidence to show that scanning a healthy person is going to do more good than harm.

"Harm?," you ask. "Aren't these scans non-invasive?"

Well, other than the radiation dose from CT (which can add up), it's true that you are unlikely to be physically hurt by an imaging scan. But they can lighten your wallet, may not offer much useful information... and may send you into follow-up rounds of further (and possibly more hazardous) testing.

Here's some more of what I answered to the original query:

The costs vary widely, from a couple of hundred dollars to thousands, and insurance usually only pays when they are recommended by a physician to check on a suspected problem... not for screening healthy people. (Mammography being an exception.) A release from the Radiological Society of North America has some numbers and contact info: http://www2.rsna.org/pr/target.cfm?ID=235

One thing to include is the likelihood, costs and risks of follow-up investigations of screening scans. For one thing, screening scans almost always find something "abnormal."

Take a look at
http://radiology.rsnajnls.org/cgi/content/abstract/237/2/385?etoc

These researchers studied 1200 whole-body screening CT scans (about a third ordered by physicians, two-thirds self-referred by the customer). Almost 90% of scans resulted in at least one abnormal finding... and almost 40% of the people who got a screening scan were told they should have follow-up tests... usually more scans.

Who pays for the follow-up tests? And what if a "non-invasive" scan results in a recommendation of a biopsy or other invasive test?

A few years ago, Elliott Fishman, MD, at Johns Hopkins told me that if people decide to get screening scans that aren't recommended by a physician, then they should be responsible for the cost of follow-up, which may be tens of thousands of dollars. He said the cost of screening scans that aren't supported by evidence of effectiveness shouldn't be dumped on taxpayers and insurance premium payers. If you want to see his quote, go to: http://www.oncology-times.com/pt/pt-core/template-journal/oncotimes/media/HoltzWholeBodyCTScanning-PTFeb102003.pdf

And Bruce Hillman, MD, Chair of Radiology at the University of Virginia, has said that screening healthy people may cost $150,000 or more per year of life saved.

Update on U.S. Breasts

The CBSNews.com web site invited me to comment on their coverage of health and medicine.

Since CBS is one of the US news organizations that didn't report the international review that highlighted some of the of risks associated with mammography screening... while instead doing a series on just the benefits... I elaborated on my comment about the puzzling differences between how health stories are reported by U.S. and British news organizations.

See the full text here:
http://www.cbsnews.com/blogs/2006/12/01/publiceye/entry2221641.shtml

Are U.S. Breasts Different?

Or is it just how we look at them?

OK, now that the headline has hooked you... here's my question: why did a review of studies examining the balance of risks and benefits of mammography get widespread coverage in the UK, but almost no mention in the US news media?

Of the two dozen stories picked up in a Google News search, almost all were from the UK, Australia and other Commonwealth nations... but there were no US news stories found. The story hasn't appeared on NYTimes.com, Washingtonpost.com or LATimes.com. CNN.com mentioned it only in its international section as part of a world news digest.

The systematic review of major mammography studies concluded that women who get mammograms are about 15% less likely to die of breast cancer... but they are also much more likely to undergo unnecessary treatment. The review concluded that for every 2,000 women who are invited to get mammograms for 10 years, one potentially lethal cancer will be detected and successfully treated. However, 10 healthy women will be treated for cancer unnecessarily. And an additional 200 women will be given false positive results.

Inform or Persuade?

The BBC and others had headlines like: "Breast Screening Concerns Raised" and "Researchers Question Benefits of Breast Cancer Screening."

Meanwhile, US news outlets ran story after story on breast cancer (October is National Breast Cancer Awareness Month)... but almost none mentioned the potential downsides of mammography. The "rah-rah" leads of these stories advocated mammography for every woman without reservation... stating flatly that "Mammograms are good" and "No more excuses for not getting mammograms."

It seems British and Australian editors have a different view from those in the US about what sort of info is relevant to their readers and viewers.

Is it the job of journalists to inform women about mammography... the benefits and the risks? Or should journalists follow the lead of breast cancer advocacy groups... and avoid talking about any doubts or skepticism, for fear such questions might dissuade some women from getting screened?

This latest review of the science... from the Cochrane Collaboration... concludes that, on balance, mammograms do reduce breast cancer deaths... but this benefit is not free.

When I mentioned this issue to some colleagues... the responses varied.

One journalist at AuntMinnie.com said that they had indeed reported on the Cochrane review.

Another wrote that wrote, "I pitched an article covering both the benefits and risks of mammography to several magazines, but so far, no one is going for it."

And then a couple of MD's ran to the defense of mammography. "It is very-well established that mammograms in the U.S. save lives, and we don't want to discourage women from getting them," wrote one physcian/journalist.

Mammography isn't the only medical topic that generally gets a free pass from US journalists. Screening tests of all types tend to be seen as inherently good... when reality is more complicated. Most reporters and editors report without question the assertion that early detection saves lives. But the fact is that screening tests often lead to further tests, anixiety and even treatment that does not always improve health or extend life.

But I'm digressing into another large and thorny issue.

What do you think? Can women handle the news that mammography is not perfect... and that the promise of life-saving detection comes with hazard of anxiety and unncessary treatment?

"Celebrating" the end of cancer treatment

Today I heard from a fellow health journalist who was having trouble with a story. Here's what she said her editor at a national magazine wanted her to write about:

"The story is about cancer survivors doing something unique/amazing/different/unusual after their treatment, to sort of commemmorate their experience and treatment. For instance, one person joined a group to climb a mountain."

But she said she was having difficulty actually finding such people.

So I wrote back to say that maybe one reason it's tough to find people who fit the story is that the editor's perception of cancer survivors may not match the reality.

As an editorial comment in the March 2006 American Journal of Nursing put it:

"According to the American Cancer Society's Cancer Facts and Figures 2005 (www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf ), the five-year relative survival rate, for all types of cancer combined, is 64%. But survival often comes at a significant cost-psychosocial, physiologic, spiritual, and existential long-term and late effects are increasingly recognized. Many don't become evident until years after completion of therapy.
"With long-term survival now a reality, many survivors find a "new normal" in their lives after cancer. They return to work, go to school, participate in recreational activities, and form and nurture families, friendships, and other relationships. But survivors of cancer frequently experience long-term changes and obstacles, such as impaired immune response, vital organ dysfunction, hormonal changes resulting in infertility, altered sexual function, cognitive changes, ongoing fatigue, depression, anxiety, family distress, and economic challenges, to mention only a few."

(see the full issue at: http://www.nursingcenter.com/library/static.asp?pageid=623591#contents )

So I wonder if the image of a survivor "celebrating" the end of treatment is more of a "And They Lived Happily Ever After" fairy tale... and not really fitting for a news article that should reflect what survivors actually have to deal with.

One of the items I've discussed with cancer experts is the burden put upon cancer survivors when they constantly see media images of amazing individuals like Lance Armstrong... and then have to wonder why they can't live up to that standard.

In closing, I offered the writer my wish for good luck with her article, because it's no fun when the facts don't neatly fit an editor's assignment.

Pitfalls of Health Info Technology

The Center for Health Transformation, founded by Newt Gingrich, just posted an interactive map of the US to highlight "transforming solutions in Medicaid." www.healthtransformation.net

The map links do not appear to work with the Firefox web browser.

One of the stated goals of the group is to:

"Create secure electronic health records and e-prescribing with expert systems to maximize accuracy, minimize errors, reduce inefficiencies and improve care."

The unreliable map is a good example of how challenging it will be to guarantee interoperability of electronic infomation systems in health care... where the stakes are very high indeed.

"Page Cannot Be Displayed" is not want you want the ER doc to see when you roll in on a gurney and she's trying to access your electronic health record.