Vol. 163 January 16, 2017 From Zero to $7,500: One Consequence of Obamacare Repeal.

January 16, 2017

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“As a doctor, I will take it and make it my mission
to heal the nation, reverse the course of Obamacare,
and repeal every last bit of it. ”
-Rand Paul

What exactly could happen if Obamacare was taken away? My daughter’s recent landing of a second part-time job offered an opportunity for me to understand the possible result in one case.

As a singer-songwriter, energy healer, and part-time retail clerk my daughter shares a common situation with many on Cape Cod; an annual income of less than $16,000, which is the current federal definition of poverty.  She is therefore eligible for Medicaid in Massachusetts. She pays no premium, has no deductible, and except for some named prescription medicines she has no co-pays. Preventative, pre-natal, and behavioral health services are covered. Her out-of-pocket cost per year is essentially zero. Some Obamacare repealers want to roll back the extension of Medicaid eligibility financed by federal subsidies. In many states that would strip this kind of  coverage from many of those newly covered under the ACA, but that is not a possibility in Massachusetts.

In my daughter’s case her new, second part-time job may push her annual income over $16,000. If so, she will no longer be eligible for Medicaid. As a part-time worker she is not be eligible for an employer-sponsored (and partially paid for) health plan. Her employer’s HR department told her she could buy a basic policy with a $2700 annual deductible for $226 a month through the school. “Co-pays varied and are difficult to predict.”  For her that is a new potential cost of $5400 out-of-pocket per year.

She got married last year and her spouse is in the same “low-income” bracket, so she inquired about a family policy (“for 2”). The answer: $400 a month at the same $2700 deductible amount for a $7,500 potential out-of-pocket cost. A $7,500 out-of-pocket cost “exposure” per year is a big nut for a family earning less than $22,000 a year.

Her other choice (besides going uninsured and paying a fine of $300-$2,085 in 2017 depending on income level) is buying an individual policy through an ACA Health Insurance Exchange. Under Obamacare any individual that is making less than 138% of the federal poverty level (about $22,000) can shop for a policy via a state or federal health insurance marketplace (also called health insurance exchange).  The exchanges can offer federally-financed subsidies of up to 60% of premium for eligible “working poor”. After lengthy website surfing, face-to-face help from the Health Connecter facilitator at a local hospital, and several phone calls with prolonged holding periods, she discovered that she could buy about the same basic policy of $2700 deductible for $226 a month through the health insurance exchange. BUT, despite providing all sorts of financial info they could not tell her…”yet” … what the premium would be and whether she was eligible for a premium subsidy. She was told that “things were in flux”, and that she could get a “call back in a week or two about that”. The enrollment deadline for signing up is January 31.

Just “for the fun of it” and to satisfy my curiosity I masqueraded online as my daughter to experience the health insurance application process via the Mass Health Connector. Over three different days I persisted on the internet and on the telephone to try to get the answer to : ”What would it cost to buy a basic individual health insurance policy?”  After reviewing and clicking on 5 to 7 different logos with unfamiliar company names, after entering the same information on multiple screens, after holding for more than 20 minutes on three separate phone calls, after being passed on to three different “responders” on one phone call, and after twice being hung up on after saying that “I was currently on Medicaid, but was looking for insurance to start February 1 when I would become ineligible”, I GAVE UP THE QUEST WITHOUT AN ANSWER.

Different sites had different definitions of “basic” and most had three or more different levels of benefits (coverage). Descriptions of benefits were quite lengthy and often complex.  For instance, the Bronze (basic) Level of “Access Blue Saver II“ (from Blue Cross; the easiest comparison charts to read) offered a 9 page policy offering no preventative or prenatal care with a $3,350 deductible and $60 co-pay for office visit and $1000 co-pay for an ER visit. Silver, Gold, and Platinum “Access” policies had different benefits. I could not get any information about actual premiums without further phone calls to “licensed brokers.”

Why is this so convoluted and confusing in contrast to the simpler processes of Medicaid and Medicare? One answer is that individual insurance policies are a gamble. For instance, a life insurance policy is really a bet between you and the insurance company. If you lose (die), you win (receive all the premiums back). If you win (out live the term), you lose and the company wins (keeps all the premiums). Another answer is that 400,000 people more than 2015  are flocking to sign up through health insurance exchanges.(1)

Obamacare has not changed the basic premise of individual health insurance policies, and the insurance companies are trying to make their  “best bets”. The betting odds are not as clear as the 1:6 of Russian Roulette, though we know that lack of health insurance can be lethal. The betting odds are more like those of Black Jack. The dealer (health insurance company) is using multiple decks, other players (consumers) at the table can affect your odds, the best odds are not always intuitively obvious, and the dealer (health insurance company) can change the betting rules every year.

Medicaid and Medicare are insurance programs based on large populations and therefore need less of the gambling “tricks of the trade” of writing individual polices. Hence my support for a health insurance program based on a large population, sometimes called a single-payor system. If not “Medicare For All”, then how about state-based programs of “Medicaid For All.” (2)

References:
1. Boston Globe, pg.2, December 22, 2016, from the NY Times.
2. NEJM, 375;26, December 29, 2016, “Maintaining Insurance Access Under Trump – A Strategy”


Vol. 161 January 1, 2017 Recap of 2016 Hubslist Blogs

January 1, 2017

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“Don’t look back.
Something may be gaining on you.”
-#6 of Satchel Paige’s Guides to Good Living

Click on the date to view the entire blog.

January 1 –   “How bad is the heroin epidemic on a scale from 1 to 10?” Could physician compliance with the patient-reported pain scale have contributed to the over prescription of opioids?

February 1 –  From Z to A – Zika virus to autism with G and F for gluten-free diet in the middle.

February 15 – The “single blood drop” lab test that never panned out (my largest pile of misplaced enthusiasm and the poorest stock tip ever) and “Uber Doctor”.  The founder of Theranos was banned from engaging in any laboratory business for 2 years.

March 1 – “Smith” as the most likely name of your doctor went from #1 in 1930-39 to #4 in 1980-89, replaced by “Patel”, “Shah”, and “Lee”. The largest contingent (20%) of foreign-born U.S. physicians came from India during that period.

March 15 – Health apps (and now Alexa apparently) are not “secure” since they transmit data about your personal use back to company headquarters (at least, not to the NSA … we think)

April Fools Day – TrumpaCare Health Plan Revealed. It doesn’t read quite as tongue-in-cheek now as it did then.

April 15 – The bathroom bill and how diclofenac killed all the vultures in India and why that matters.

May 1 – Multiple private insurance companies pull out of Obamacare (ACA) which somehow continued to be attacked as a “socialistic, single-payor” scheme.

May 15 – Medical fun facts about three presidents and Obama’s prediction in third grade about becoming President and “visiting all the places in Indonesia”.

June 1 – Placebos work better as therapy if they cost more. The Chinese reduced adult myopia by getting the kids to play outside more often while 40% of U.S. toddlers (under 2 yo.) already play with an electronic mobile device.

June 15 – Annual update on sun and bugs … actually anti-sun and anti-bugs.

July 15 – Medication Assisted Treatment (MAT) of opioid/heroin addiction works pretty well without making the patient lie down. So, more beds are NOT needed and are NOT the answer.

August 1 – Five reasons that playing video games improves learning in kids… IF the content is right.

September 1 – Various “redefinitions” of medical “truths” about teen age pregnancies, blood pressure medicines, and lead exposure.

September 15 –  How to be an appropriately skeptical reader of media reports of “medical advances” … aka “Beware of Percentages” in hyped reports of improved outcomes.

October 1 – “Light up or not.” Pros and cons of recreational marijuana referenda on 8 state ballots.

October 15 – Asking your doctor to make you a “DNT ” after “a certain age”. Nine medical tests that can be optional after 65 because their benefits are elusive and results may cause more problems than they are worth. Choose Wisely website.

November 1 – A really scary clown CAN kill you. The same physiological mechanism may have caused Debbie Reynolds’ sudden death while she was planning Carrie Fisher’s funeral.

November 15 – Real health CARE reform is the way to improve on the health care INSURANCE reform of Obamacare.

December 1 – Less old people are leaving their car keys in the refrigerator while Germany and Japan residents gain more weight in a year than we do.

December 15 –  Though the stakes are high (lack of health insurance causes 45,000 unnecessary deaths in the U.S.) it will probably take two years for Trump and the Republican Congress to turn back the accomplishments of Obamacare.
I am hoping that as an unintended consequence of their reframing of the ACA, the law will actually be improved.

HAPPY NEW YEAR from an eternal optimist.


Vol. 160 December 15, 2016 ACA or Not ACA, That Is The Question.

December 15, 2016

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As Trump continues to form his cabinet and Obama counts the days left while Hillary remains hidden in the woods, speculation about what will happen to the Affordable Care Act (ACA) is wide-ranging. Will it be repealed? CAN it be repealed? What will replace it? What if nothing replaces it?

It may help to remember that the vast majority of citizens who had health insurance before ACA were already heavily subsidized by government funds via Medicare, Medicaid, and tax subsidies for employer-sponsored insurance ($300 billion for the employer-sponsored policies alone). Studies have shown that 5% of the population accounts for 50% of health expenditures. The least costly half of our population accounts for 3% of the expenditures. (This is, of course, the essential element of risk spreading that makes insurance of anything “work”.)

ACA accomplishments since 2010

23 million citizens have gained health insurance coverage
-coverage that is not denied due to pre-existing conditions
-coverage of children up to 26 yo. on parents’ policy
-more than half of those (13.7 million) gained coverage under expanded Medicaid (by increasing the eligible income levels)
-all but 19 states took the federal subsidy to expand Medicaid coverage

Uninsured citizens dropped from 16% in 2010 to 9% in 2016
91% of U.S. citizens now have health insurance coverage (Spoiler Alert: in our big, or should I say “Hu-u-y-ge”, country that 9% translates into 29 million citizens still un- or underinsured.)

All this without additional net cost over the cost of medical services that was predicted in the U.S. without the ACA, i.e “no net increased cost due to the ACA.” (The largest single source of spending increase since 2013 was “retail pharmaceuticals”.)

Reduced “gender bias” by mandating maternal health benefits (coverage of contraception) as part of essential benefits package.

Mandated some mental health service coverage.

Mandated some coverage of substance abuse services.

What about repeal?

Unlikely, but possible. Outright repeal could immediately create another 23 million people without health insurance which would dump all that cost burden back on the states, the insurance companies, and the health care providers.

Repeal would require 60 votes in the Senate, and the Republicans are 8 short. There is speculation that some Democrats running for reelection in 2018 might join a repeal vote knowing that some of their Democratic colleagues that supported Obamacare lost reelection in 2016. The Gallup poll currently puts the public attitudes toward Obamacare at 50/50 “favorable/unfavorable”.

“Replacement” of selected provisions is more likely since it could be done as part of the “budget reconciliation process” which requires only a simple majority of 51 votes.

Replacement?

Coverage to age 26 on your parent’s policy and ban on denying coverage of pre-existing conditions are so popular that they are here to stay.
What parts might Republicans target to replace?
(An “ACA repeal bill” passed by the Senate in 2015 and vetoed by Obama gives us some clues).

Individual mandate – Even though this was proposed by Republican Mitt Romney and successfully passed the Supreme Court test as a tax, this penalty for not getting health insurance rankles the Republicans, and a sizable portion of the public. Proponents argue that it is essential to incentivize “healthy people” to buy insurance, a fundamental principle of spreading the risk over a large group.

Block grants to the states and/or vouchers for Medicare – Block grants would change this federal standard “entitlement” program into a state-controlled one with variable benefits and premiums. Vouchers, touted as making consumers more “powerful in the marketplace”, really shift the obligations (“unpaid bills”) to the states and health care providers

Reduce income level eligibility for Medicaid from the ACA level of 138% of federal poverty level (about $22,000 for a couple) back down to about $16,000 a year for a couple.

Middle-class subsidies via insurance marketplaces to be replaced by Health Savings Accounts (HSA), tax credits, across-state line insurance policies, and reestablishment of high-risk pools. All of these are advantages to people who have income, often sizable incomes.
-70% of HSAs are currently held by people with over $100,000 annual income.
-Many insurance companies already sell across state lines, but this provision would free companies from state mandated benefits and other state regulations.
-Reestablishment of high risk pools could provide higher premium policies for those with chronic diseases without unduly penalizing healthy individuals. This reflects a trend back toward indemnity or catastrophic insurance policies with few preventative benefits.

Rescind the new taxes to fund the ACA – details on how to pay for replacement provisions TBD.

Maternal health benefits– Trump suggests making contraception available over-the-counter without a prescription, thus avoiding the problem of exempting churches from this mandated benefit. Planned Parenthood would, of course, be defunded.

Medical liability reform – Though a cherished symbol of support of and a psychologically warm and fuzzy concept to physicians, all studies show that no significant cost reductions occur from tort reform because the actual cost of “defensive medicine” is very small compared to the total.

What about ACOs?

Remember them? Accountable Care Organizations are physician groups and hospitals organized together to reduce costs without degrading quality. The first ACOs, so-called “Pioneer” ACOs, could keep a share of any savings if they delivered care to a defined population at a cost below a “target cost” without missing any of the “quality targets.” If they overshot the “target cost”, they would owe money to the federal government at the end of the year.

This is the last year for the original 32 Pioneer ACOs, and only 16 remain in the program. Half have withdrawn from their contracts because of losing money, continuous wrangling over targets, and lack of flexibility in defining risks and benefits. The “Next Generation” ACOs are due to sign up in January 2017, and most will opt for sharing savings without taking financial risk for losses.

Bottom Line:

The vetoed 2015 Senate “ACA repeal bill” had a two-year transition period embedded in it, so even if a repeal bill is passed and Trump signs it the loss of health insurance will not be immediate. Many political experts, if we can still use that label for them after this election, suggest that even “replacement” of ACA provisions will be politically difficult and will take at least two years to pass. A new study by the Urban Institute shows that Paul Ryan’s proposed Republican replacement plan would result in more uninsured citizens than existed before ACA. 80% of those losing insurance would be part of a working family.

How high are the stakes? A 2009 study by Harvard Medical School and the Cambridge Health Alliance estimated that the lack of health insurance led to almost 45,000 unnecessary deaths. “Lack of health insurance can be fatal.”

So, for a variety of reasons, the next two years will be “vel-l-ly in-ter-esting” In the meantime if you have health insurance through a ACA-based insurance marketplace make sure you re-enroll by January 31 to continue coverage.


Vol. 159 December 1, 2016 Dementia Is Going Down, Weight Will Go Up

December 1, 2016

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The incidence (number of new cases per year) of dementia in the U.S. is apparently declining.

The Framingham Heart Study which has been monitoring 5,200 adults and 5,000 of their off spring since 1975 revealed in February 2016 that the decrease in the rate of new dementia cases was about 20% per decade. The FHS statistics are based on a variety of data sources including questionnaires, medical records, and some direct examinations.

A more recently published study using direct testing of a larger (21,000), more diverse, over 65 year old (average age: 75) U.S. population reveals that the incidence of dementia decreased from 11.6% in 2000 to 8.8% in 2012. In case you want to “study up” for your test, it included:
recalling 10 nouns immediately and then a little later
serially subtracting 7 from 100
counting backwards from 20

Those with more years of education had a lower risk of dementia. (better “test takers” obviously).
Diabetes increased the risk for developing dementia by 39%. Ominously the incidence of diabetes in this studied population increased greatly from 9% in 1990 to 21% in 2012. Despite that, the overall incidence of dementia did decrease. Nobody knows why.

The Framingham Heart Study findings showed that obesity increased the risk of dementia. In this study obese people had a 30% lower risk for dementia, and in fact, underweight people had a 2.5 fold increase in their risk!

As Dr. Denis Evans, one of the study’s authors, said, “Its very complex.”

dementia-cartoon

Speaking of obesity, the holiday eating season is upon us. Almost all of us expect to put on a little weight. Three scientists from three different countries (Finland, France, and U.S.) nicely graphed the average weight gains by month in three countries (Japan, Germany, and U.S.). No surprise. The Christmas season was the winner in all three countries, but Germany was the leader.

holiday-weight-gain

That Golden Week spike in Japan at the end of April and first week of May is when 5 of the 9 official Japanese holidays are clustered and most people take the whole week off.  (NEJM 375:12 Sept. 22, 2016, p. 1201)

Though the graph is impressive with its spikes and valleys the average weight gain in the U.S. measured in the 10 days after Christmas was only 0.7% or 1.33 pounds; much, much less than the 7-13 pound gains per week or two reported by some cruise ship travelers.

The bad news is that even though half of your holiday weight gain is lost shortly after the holidays, half of the weight gain remains until the summer … and beyond, which resets your baseline weight for the next year.
Oh, well. “Life is short. Have dessert first.”


Vol. 158 November 15, 2016 REAL Health Care Reform

November 15, 2016

Trump 2Mr. Trump (now that he is President-elect we need to show “Donald” some respect) has recently said that he may keep the Affordable Care Act (Obamacare) ban against denying coverage for preexisting conditions as well the extension of parental policies to  26 -year-old children because “everyone seems to like those provisions”. As President-elect Trump begins to soften his bombastic, total opposition to Obamacare (and replace portions of “the Wall” with a fence) the 1.2 trillion dollar question becomes, “what is he going to do next?”

Since passage of the ACA 20 million Americans have gained health insurance coverage. 63% of that gain was produced by expansion of Medicaid in the half of our states that choose that federally subsidized route under ACA. The other 40% of increased coverage came from the federally subsidized premiums on policies purchased through health insurance exchanges. Not every state established health insurance exchanges, and  those states that did establish exchanges were twice as effective in getting people to enroll in health insurance.

The “individual mandate”  that was resisted so fiercely by Republicans as “another government tax” was originally composed by Governor Mitt Romney and  became law in Massachusetts years before the ACA passed. The  ACA 2014 “individual mandate” was  a $95 fine if you did not obtain coverage, and it proved to be fairly ineffective. In 2016 that fine goes up to $695 (or 2.5% of your taxable income), so it may prove more of an incentive this year. (1)

What about the rest of the ACA? We shall see, but just tinkering with the ACA (“repeal/replace” or “fix”) raises the concern that we may waste a lot of time and energy getting entangled in the trees while losing sight of the forest.

Can we get REAL about health care reform, or do we just continue arguing about health care insurance? It just so happens that a physician colleague of mine wrote a succinct, clear, eminently quotable Op Ed column about that question in our local paper yesterday! (2)  I  am going to shamelessly plagiarise* it.

“We have given providers incentive to ration care and collect data while ignoring non-provider stakeholders responsible for major system expenditures.”
.             Like: big pharma that advertises directly to consumers for great profit
.                       medical device companies with excellent, high-paid, effective lobbyists
.                       health insurance companies with more lawyers, consultants, lobbyists, and way more overhead than Medicare.

“We seem determined to jump through ever more hoops to limit provider options while the rest of the industry revels in the lack of any kind of market control.”

“Resources that used to represent [provider] profit or ability to retain staffing are now spent on fighting insurance claims and bolstering hospital advertising budgets.”

New payment-bundling schemes with buzz words like “pay for value”, “pay for performance”, and “population basis” will “transfer unprecedented financial risk to providers.”

“Constraints placed on health care providers cannot adequately repair our system.”
What actions can repair our system according to Dr. Urbach?
.              “expanding the public option should not be politically toxic” when  50% of Americans are already covered by government
insurance;
.               reforming malpractice tort law to save big dollars by reducing the costs of “defensive medicine”;
.               having thoughtful discussions about appropriate use of resources at end of life;
.               allowing Medicare to negotiate drug and device costs;
.               devoting adequate medical resources to the mentally ill rather than putting them in jail.

“We must stop pretending that exerting ever more financial pressure on our doctors, nurses, and hospitals (while ignoring bigger fish) will get the job done.”

Now, Dr. Urbach is not a disgruntled primary care physician who is whining about poor reimbursement and non-appreciation of his skills and talents. He is an experienced, well-respected cardiologist, a specialty near the top of the payment and prestige pyramids, who shared these reflections on the occasion of his son’s graduation from medical school. He prays that his son and his peers “will not only make themselves into great clinicians, but that they will also do what my generation of providers largely failed to do – make themselves into a courageous political force that can effectively force comprehensive reform of the heath care system by demanding sacrifice from all stakeholders, not only the caregivers.”

And I say, Amen.

References:
1. New England Journal of Medicine, 375;17,  October 27, 2016, p.1605
2. Cape Cod Times, November 14, 2016. “Let’s get real about health care reform”; David Urbach, MD
* “When you copy one person’s words, it is plagiarism. When you copy many persons’ words, it is research.”


Vol. 157 November 1, 2016 Can You Be Scared To Death?

November 1, 2016

Hub thumbnail 2015BOO!!

 Did I Scare You?

Can you be scared to death?
The short answer is yes, absolutely.

Dr. Martin Samuels, Chief of Neurology, Brigham and Women’s Hospital summarized the mechanism in Scientific American  as the familiar “fight-or-flight” response. The outpouring of adrenaline in our blood in response to stress can inundate the rhythm center of the heart, causing it to lose control, resulting in ventricle fibrillation and persistent contraction or “cramping” of the heart muscle. That stops the effective pumping of our heart, and we drop dead. (1)

The “flight-or-flight” response was first described in the early 1900’s by William Cannon, Chairman of Physiology, Harvard University. It can be in reaction to any strong emotional event, pleasurable as well as not-so-pleasurable. It may cause sudden death during a passionate religious experience or sexual intercourse. I have written previously about increased cardiac deaths in both Germany and Los Angles related to close soccer championship and American  Super bowl games. During the week after 9/11 there was an uptick of cardiac deaths in New York city. Apparently, even getting a hole-in-one can kill you!  It is this mechanism that explains the limited successes of voodoo curses, but unlike other forms of complimentary medicine like acupuncture and Reiki you have to believe in voodoo to have it work.

So much for the medical side of things. What does the law say? Can you be sued or charged with a crime if your action leads to a person’s death? It depends on your intent.

If you inadvertently harm a person you must likely will be held harmless. If you intentionally surprise or seek to scare a person and they die, you can be charged with “negligence” and found guilty.  In 1979 a 20 yo.man who broke into the home of a 79 yo. woman and took her hostage was sentenced to life imprisonment in federal court after she died from a heart attack while in his custody. But, the actual charges were “kidnapping” and “negligence” – failure to seek treatment for her.

What about just a good old fashioned  “blood-curdling scream”? Well, that can cause you trouble too.  Dutch physicians studied 24 healthy volunteers and found that viewing a scary movie, like “Halloween 1, or 2, …#13”,  could cause the initiation of the “coagulation cascade” in their blood. This cascade involves multiple “factors” (proteins) that cause us to form a clot when cut, so that we don’t bleed to death from a simple cut. The cascade is started by Factor VIII, and Factor VIII levels increased by an average of 11 units after viewing a horror film. No increase was seen after watching an educational film. An increase of 10 units of Factor VIII increases your chance of forming a blood clot by 17%. (2) Forming a blood clot inside a vein can lead to a pulmonary embolism, another cause of sudden death in apparently healthy people.

If you are reading this blog it means that you have survived the creepy clowns and other scares of Halloween 2016, but don’t be smug.
The Presidential election is just days away, so you are still at risk of being “scared to death” by a clown.

HAPPY HALLOWEEN

REFERENCES:
1.’
“Can a Person Be Scared to Death?”, Scientific American, January 30, 2009
2.  “Blood Curdling Movies”, British Medical Journal, December 16,  2015


Vol. 156 October 15, 2016 Adding “DNT” to Your Medical Record Before “DNR”

October 15, 2016

 

Hub thumbnail 2015At our last weekly gathering of the “Over 70 Men’s Breakfast Club” we heard from one of us the following about visits to two of his physicians on the same day a week before:

Gastroenterologist: “Congratulations, your colonoscopy was entirely normal.”
Patient: “Great. When should I schedule the next one?”
Gastroenterologist: “Well ,, er..um .. you are over 75 you know. At your age it …er…um.. wouldn’t make any difference.”

The same day with his primary care physician:

Patient: “I think my urine stream is slowing a bit. How’s my prostate?”
PCP: “Your prostate exam is absolutely normal.”
Patient: “What about a PSA test?”
PCP: “ We don’t do those for men your age. It …er…um…wouldn’t make any difference in the long run. Oh, by the way, who’s your Health Care Proxy, the person who can make you DNR in case you can’t speak for yourself?”

Over our eggs and bacon (one member, our oldest, has oatmeal and berries instead) we reached the consensus that his medical record should be stamped with a “DNT: Do Not Test”.

Here are some of the “unnecessary” screening tests that he and others “of certain ages” should skip:

PSA: Rarely done under 50 yo. or over 70 yo. and now being questioned as of mixed benefit for any man. Screening does not reduce the very, very low death rate from prostate cancer and false positives are common. Further investigations of false positive results can cost at least $1,200 per patient, and treatment of truly positive cases can cause incontinence and/or impotence without any significant medical benefit.

Colonoscopy: rarely done under 50 yo. and never over 75 yo. as a screening test. Repeat colonoscopy after an initial normal one detects cancer of the colon no better than a periodic fecal occult blood (FOB) test on a stool sample done by your primary doctor.

X-ray, CT scan or MRI for low back pain without other symptoms: Back pain usually gets better in a month whether you have imaging done or not. Surgery is often done on image irregularities which have no causal relationship to the pain.

Pap smear: Every 3 years for ages 21 to 30. Every 5 years from 31 years to 65. None after 65 yo. “Abnormal” but non-cancerous cells can be detected by this test, but do not need treatment. Pap smears are recommended even if the woman receives the HPV vaccine (Gardasil) because the vaccine does not cover all viruses that cause cervical cancer.

Vitamin D: Vitamin D is the current “vitamin in vogue”. Speculations about relationships with heart and other diseases are riff, but the data is not that conclusive. Many people have low vitamin D levels (as currently defined) but very low levels associated with real illness are extremely rare. Oral vitamin D treatment has not been shown to reliably raise vitamin D levels. A 10 minute walk in the sun and a breakfast with orange juice and eggs supply more than enough vitamin D. (Note: The blood test itself is not expensive, but in 2011 Medicare paid $224 million for vitamin D screening on seniors.)

Testosterone level:  Despite the plethora (I am told) of late night TV ads selling gels, patches, and pills for low testosterone among middle age and older men, treatable “low testosterone” is rare.  Unless a man has one or two of 9 specific symptoms ( and erectile dysfunction (ED) is NOT one of them) a testosterone blood level screen is not recommended. Even if the level is low (under 10 nmol/L – I’m not sure what these units are either, except that they are very small ) a treatable diagnosis rests on the clinical history and exam, not the blood test.

Bone Density: Never under 50 and rarely over 70 in men without risk factors like fractures, heavy smoking or drinking, or very low Vit. D levels. Women could get one done at age 65, but  “treatment” of low bone density with costly medications (also advertised a lot on TV) has not been shown to have much benefit.

Annual EKG or stress test: Does not add any useful information for the asymptomatic person.

Whole Body Scans: Besides the cost and the large amount of radiation involved, these scans should be avoided because they do NOT find asymptomatic cancer. Less than 2% of the scans find a true mass and most of those are benign or inconsequential. In over 33% of scans “abnormal findings”, sometimes called “ditzels” by radiologists, lead to unnecessary and expensive further imaging tests that do not result in any benefit to the patient. (This test was previously heralded by this blog as a good Christmas present for an enemy)

References:

1. Choose Wisely is a list of unnecessary medical tests complied by the American Board of Internal Medicine from suggestions of numerous other specialty groups and published widely in Consumer Reports and other periodicals.


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