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The Question Isn’t Whether We Are Overdiagnosing Cancer, But How Much

The Question Isn’t Whether We Are Overdiagnosing Cancer But How MuchMedical experts now agree that as a result of aggressive screening programs, we have an epidemic of cancer overdiagnosis in the United States. With mammograms finding tiny cancers and PSA tests discovering unpalpable prostate cancers, we are now unearthing some cancers too early for our own good.

What do experts mean by “overdiagnosis,” you ask? First, overdiagnosis is not the same as a misdiagnosis. If a pathologist looks under a microscope and classifies a group of benign cells as being cancerous, that is a misdiagnosis. Such misdiagnoses are an important consequence of cancer screening, causing patients to experience unnecessary anxiety and to undergo unnecessary treatments. Because no pathologist is perfect, aggressive screening programs will, by definition, lead to increases in such misdiagnoses. But these misdiagnoses do not qualify as overdiagnoses, the way experts use the term.

Second, overdiagnosis is not the same as a false positive test result. When a mammogram reveals a suspicious shadow, or when a PSA test is elevated, physicians usually follow up with additional tests, often culminating in a biopsy of the suspected lesion. When that testing reveals that no cancer is present, the screening test (the mammogram or the PSA test) is said to have created a “false positive,” result. It sent out a false alarm. Once again, false alarms are an important side effect of cancer screening. And more aggressive screening programs (yearly mammograms rather than every other year, for example) will necessarily lead to an increase in false positive test results. By some estimates, women beginning annual mammograms at age 40 will face a 50% lifetime risk of a false positive test. In other words, this is a burden of screening that we need to keep in mind when deciding how aggressively to look for a cancer. But false positives are not the same thing as overdiagnoses.

So what does it mean to overdiagnose cancer?

According to cancer epidemiologist Ruth Etzioni: “Overdiagnosis occurs when screening detects a tumor that would not have presented clinically in the absence of screening.” For example, if a mammogram reveals a tiny breast cancer in a 103-year-old woman, a cancer that if left alone would not grow large enough to cause symptoms (much less death) for another decade, that mammogram would probably have overdiagnosed her cancer—if she had never had that mammogram, she would have lived the rest of her life (maybe to 104 or 107-years-old) blissfully unaware that a small breast cancer was growing inside her body.

The example of this hypothetical 103-year-old woman is obviously an extreme one, meant to illustrate what experts mean by overdiagnosis. But it makes one thing clear. Cancer overdiagnoses are cases of real and true cancer. In this hypothetical case, for example, the tumor in this woman’s breast really was malignant. The mammogram did not lead to a misdiagnosis or to a false alarm. Instead, the mammogram discovered a cancer that, while real, would not have ever influenced this woman’s life. In her case, in fact, the diagnosis of this cancer would only act to harm this woman, by causing anxiety and potentially by leading to harmful treatments. (To read the rest of this article, please visit Forbes.)

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Don’t Be Afraid to Team Up with Your Doctor about Healthcare Costs

Los Angeles TimesHere is a fine story in the Los Angeles Times written by about the importance of talking with your doctor about your out of pocket medical costs.

Despite high medical costs topping Americans’ list of financial concerns, many of us have a hard time telling our doctors that the care they’re prescribing may break the bank.

As part of a recent awareness campaign called “I Wish My Doctor Knew,” the online health social network Inspire asked patients and caregivers what medical concerns they wish doctors better understood.

In more than 700 responses, about 20% dealt with insurance coverage, disability insurance coverage paperwork, and out-of-pocket medical costs.

“What we see every day in our online community, and through this campaign, is that patients don’t discuss fully with their doctors the financial toll of [their] disease,” said John Novack, Inspire’s communications director. “Many patients seem reluctant to bring it up at all … yet it’s a very real hardship and it certainly affects their quality of life.”

Ellen Robin of Oceanside, Calif., can relate. The 59-year-old healthcare contract manager has a chronic condition that led to a heart attack six years ago.

Since then, she says, she has collected a cabinet full of prescription drugs worth thousands of dollars. She abandoned most after her doctor told her to stop them — either because they didn’t work or caused unbearable side effects.

“Every time I get a prescription, I pay my co-pay of $30 or more,” she says. After a week or two, many times she’d have a bad reaction and her doctor would advise her to just stop taking it. “It’s a waste.”

Still, letting her doctor know didn’t come easy. “I do have anxiety about talking money with him,” Robin says.

She’s not alone. The financial strain of medical expenses is a tough conversation for many patients to initiate — despite the fact that high costs prevent millions of people from getting needed care.

A report by Families USA, a Washington healthcare advocacy organization, found that just over 1 in 4 adults with private insurance policies last year went without needed medical care because they could not afford tests, treatments, follow-up care and drugs.

One of the biggest causes of “not taking the medicines their doctor prescribed — or getting the tests their doctor ordered — is that patients can’t afford it,” says Duke University professor Dr. Peter Ubel.

“This deserves priority in the doctor-patient encounter,” Ubel says.

Experts offer a few recommendations for broaching the subject of money with your doctors.

(To read the rest of this article, please visit the Los Angeles Times.)

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These Americans Are Rich – Should We Celebrate?

Expensive medicineAmerican manufacturing has declined precipitously in the past few decades. Companies that were once the source of fabulous wealth for Americans – the U.S. Steel profits that enriched the Carnegie family, the Ford Motor F -1.29% Company profits that enriched its eponymous family – are now struggling to keep up with foreign competitors.

Thank God for American pharmaceutical companies, which are a rare source of wealth in United States. The CEO of Eli Lilly , John Lechleiter, made $11.2 million in take-home pay in 2013. That was dwarfed by the $18.1 million pay package of Richard Gonzalez of AbbVie ABBV +0.24%, which still couldn’t compete with the $20.5 million that Miles White made running AbbVie’s former parent company, Abbott. And Pharma isn’t just a source of hefty c-suite income. Senior chemists at pharmaceutical companies bring in a median salary of $76,000 while senior biostatisticians make around $135,000. Drive through beautiful suburban neighborhoods in Jersey, Indianapolis, and Raleigh-Durham, and you are witnessing the benefits of this thriving industry.

I’m really glad the American pharmaceutical industry is a success. So why did a recent conversation I had with a retired pharmaceutical executive end with him storming away after proclaiming: “I’m sure glad you’re not a member of Congress!”?

Let me explain. (To read the rest of this article, please visit Forbes.)

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What Physicians Could Learn from Accountants and Veterinarians

What Physicians Can Learn From ARebecca Plevin, from KPCC public radio in California, is quickly becoming one of my favorite health reporters. She is really digging in to the strange world of health economics. Here’s a nice piece she did, comparing how people talk about costs when meeting with financial counselors versus veterinarians versus, of course, going to see their own doctor:

Here at Impatient, we’ve been exploring why doctors and patients don’t often discuss the costs of health care. I’ve also been offering tips on how both can play a role in making these conversations a part of routine care.

But this concept of discussing costs in the exam room is still foreign to a lot of people. So today, for a radio story that’s airing on KPCC, I provide examples of situations where these types of cost-related discussions occur more frequently.

My search for models for better conversations about health costs brought me to the Hollywood office of accountant Persida Matei.

She says she asks her clients a lot of questions when she first starts working with them. Questions, she says, like, “are you married? Do you have children? What is your age? What is your tolerance to risk?”

She says she would never offer investment advice without first understanding her client’s short- and long-term goals. She explains: “It may be a great investment, but not a great investment for them. And then you’ve done them a disservice.”

What can we learn from Matei’s interactions with her clients?

For one, it’s important that doctors know if a patient is on a high-deductible health plan, and is digging deep into her own pocket to pay for recommended procedures and medications. As I’ve reported, a doctor might then tailor any recommendations to the patient’s specific needs.

Dr. Peter Ubel, a physician who studies health care costs, is a big advocate for these types of discussions.

“I used to tell my patients, ‘look, I’m the expert on the medical facts, but you’re the expert on you,’” Ubel says. “And so I need to understand you better, to help you figure out what’s best.” (To read the rest of this article, please visit KPCC.)

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Showing Doctors How to Lower Healthcare Costs

KPCCThere are lots of things we need to do to get healthcare costs under control in the United States. Critical to most of our efforts, however, is to get physicians to practice cost-conscious care. Here is a nice story on this topic, from Rebecca Plevin at KPCC public radio in California:

As regular readers of Impatient know, I’ve been on a mission recently to encourage consumers to talk with their doctors about health care costs.

Everyone I’ve spoken with for this series – patients on high-deductible health plans, patient advocates and a few doctors - agrees that through these conversations, patients and doctors can work together to potentially lower people’s out-of-pocket costs.

But as Duke University professor Peter Ubel points out, patients can only have so much influence over their doctors’ recommendations.

“One of the biggest limits to the power of health care consumerism – of patients to discipline the health care marketplace – is the fact that doctors make most of the medical decisions,” Ubel tells me.

He offers this example:  If a patient goes to see a doctor for back pain, and the doctor recommends an MRI, the patient can shop around for the most affordable MRI. But, he says, “I, as a patient, might not know that I didn’t need any MRI.”

Convincing doctors to avoid ordering unnecessary tests, or avoid prescribing expensive brand name drugs when generic versions are available, requires a larger, cultural shift in health care. One health system in Northern California has developed a way to concretely change physicians’ behavior.

Could this be a model for a cultural shift toward more cost-conscious, high-quality care? (To read the rest of this article, please visit KPCC.)

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What Do Cancer Centers Think Patients Are Looking For?

What Do Cancer Centers Think PicIf you were a cancer center trying to get patients to come to receive care at your facility, what message would you send them? In other words, what would you as a cancer center director think people would value in choosing a place to receive cancer care?

One way to answer this would be to survey cancer center directors. You could conduct face-to-face interviews or written surveys. You could hold focus groups, if you could get all the directors in a room together.

But Laura Vater and colleagues from the University of Pittsburgh had a much cleverer and simpler way to answer this question, published recently in the Annals of Internal Medicine.

They analyzed cancer center advertisements. They collected national advertisements from U.S. consumer magazines and television networks, dutifully analyzed the topics covered in each ad, and tabulated the results. What they found is telling, if not totally surprising. (To read the rest of this article, please visit Forbes.)

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Using More and More Medical Care

Recently, Dr. R. Adams Dudley, director of the UCSF Center for Healthcare Value, circulated a picture illustrating rapid growth in the use of tests and other imaging procedures between 2000 and 2013. I thought it deserved further circulation. It reveals 60-80% expansion of testing and imaging, with only – only? – a 40% increase in the use of major procedures:

Using more and more medical care

Of note, there is a tapering off near the end of this time period, coinciding with a tapering off in the growth of healthcare costs. I’m eager to see what happens to these trends going forward.

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More Healthcare Job Growth

The other day I posted a picture on job growth in the United States, in healthcare versus other parts of the economy. It showed that most growth was healthcare related. Well here is another picture, from the Wall Street Journal, showing just how the U.S. economy has changed, and how much healthcare has come to dominate it:

More On Healthcare Job GrowthI’m not sure this is sustainable.

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The Upside of High Healthcare Costs: Lots of Jobs!

Here is a quick review from the Commonwealth Fund showing what happened to jobs in the United States since 2000. A dramatic growth in healthcare jobs, and almost no growth in the rest of the economy:

Upside of High Health Care Costs Lots of Jobs

Something to keep in mind, because if we ever get healthcare costs under control, we had better hope to find new jobs elsewhere in the economy.

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Money Talk in the Doctor’s Office

Money Talk in the Doctors Office NBC NewsHere is a well done story out of a public radio station on the new movement to get physicians to discuss out of pocket costs with patients. Warning– I’m a serious proponent of this practice.

Dear Impatient readers, you may have noticed that we’re writing a lot about the importance of asking about the cost of your health care. It’s part of our ongoing mission to give you the tools to navigate our rapidly changing medical system, particularly with regard to how much care costs.

Along the way we’ve talked about how patients – especially those on high-deductible health plans - should broach issues of cost with their doctors, even if it means having potentially awkward conversations. These discussions, experts advise, could spur doctors to be more cost-conscious when ordering tests or prescribing medications.

This week, we turn the tables and talk to some doctors who think they and their colleagues also need to be prepared to have these conversations.

Do no (financial) harm

Many doctors don’t think about health care costs, says Dr. Neel Shah, an assistant professor at Harvard Medical School. One reason for that, he says, is that they haven’t been trained to do so.

“In medical school, not only was I not taught anything about health care costs, but I was specifically taught that health care costs were not my concern,” says Shah, who’s also the founder and executive director of the non-profit Costs of Care.

Dr. Jeff Kullgren, an assistant professor at the University of Michigan Medical School, takes that a step further.

Kullgren went to medical school “not that long ago,” he says. The professors there taught him that a patient’s “ability to pay for a service should not be a major factor in deciding what kind of health care that patient needs,” adds Kullgren, who is also a research scientist at the Center for Clinical Management Research at the Veterans Affairs Ann Arbor Health System.

Both doctors have since rebelled against this part of their education. They say they’ve realized that as the health care system changes, the ethos to “do no harm” must include patients’ finances.  Shah and Kullgren argue that turning a blind eye to the cost of care only allows costs to mount – both on the system and on individual patients.

Shah recalls that as an intern at a hospital, he would order MRIs without knowing their cost. (Impatient readers might recall that another doctor told us last summer that he, too, had ordered thousands of ultrasounds and CAT scans over the course of his career without ever knowing their prices.)

“If you’re ordering off a menu that doesn’t have any prices on it, it’s very easy to get filet mignon everyday,” he explains. And more and more patients are struggling to pay for that filet mignon out of their own pockets, Kullgren points out.

What patients care about

Doctors may not have been taught to consider health costs, but that doesn’t mean they’re averse to discussing them.

You could dive headfirst into that awkward conversation I mentioned a few weeks ago, or ask some of these questions that patient advocates suggested last week.

No matter how it begins, the conversation is worthwhile – and should he happening more regularly, says Dr. Peter Ubel, a physician and behavioral scientist at Duke University who frequently writes about health costs.

Like Shah and Kullgren, Ubel believes doctors need to take a more proactive role.

Just as a financial advisor talks to a client about short- and long-term goals before suggesting a retirement savings plan, doctors should spend five minutes finding out what their patients care about before giving medical advice, he argues.

“Sometimes the best alternative is what the patient cares about,” adds Ubel.

(You can read the rest of this article by clicking here.)

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