Are Medical Screening Tests A Bad Idea?

DrRich | October 31st, 2011 - 6:08 am

Podcast:

Just last week, DrRich wrote a post explaining why medical screening tests, under our new paradigm of centralized healthcare, will always be found to be ineffective and harmful. Therefore, it will be the job of the United States Preventive Services Task Force (USPSTF)*, after making a great show of examining randomized clinical trials as if the result is not a foregone conclusion, to declare such tests useless.

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*Regular readers will recall that the Obamacare legislation has transformed the USPSTF from its former status as a mere (one might say milquetoasty) advisory board, which made recommendations on preventive health that doctors and patients could take or leave alone, into an extraordinarily powerful GOD panel (Government Operatives Deliberating) that determines, definitively, which preventive services are to be covered and not covered by private insurers, Medicare, and Medicaid.
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DrRich thought his observation would be viewed by many as a bit “out there,” and that proponents of Obamacare would accuse him (as they so often do) of being paranoid and reactionary. So imagine his surprise when, just yesterday, the New York Times published a “news analysis” which aggressively begins selling the public on that very notion – that medical screening tests are, by and large, a bad thing to do.

Even DrRich thought the Progressives would be somewhat circumspect about breaking such remarkable and counter-intuitive news to us in the great unwashed – especially considering that they have just spent the last three decades teaching us just the opposite.  But then he recalled their smooth, unapologetic and entirely unremarked transition, around twenty years ago, from sounding the alarm about global cooling to catarwauling about global warming.

And he reminded himself that when you are a Progressive, history always began 10 minutes ago.  And this turns out to be a great convenience.

In this case it is particularly convenient, when you consider the passionate declarations by Ms. Pelosi and others in 2009 that the watchword of Obamacare – indeed, the very key to the dramatically lower costs we would realize with this new legislation – would be “prevention, prevention, prevention.”

It is always risky to speculate on what is actually going on in Ms. Pelosi’s head, but certainly the public health experts who helped devise Obamacare understood the truth all along.  Namely, it is axiomatic that medical screening tests will always, without exception, cost the healthcare system far more money than they can ever save the healthcare system. And therefore, medical screening tests will have to be suppressed – which is precisely why our new healthcare law provides the mechanism for doing so.

While readers should never doubt DrRich, he is aware that, sadly, many do.  And so it may be necessary to review why screening tests are invariably a money-losing proposition:

  • The screening tests themselves are often expensive.
  • Screening tests often produce false positive results, so additional (often invasive and always costly) testing will need to be done to confirm or deny the diagnosis.
  • If the diagnosis is made, treatment will be applied which is often dreadfully expensive.
  • The diagnostic testing is often “too sensitive,” such that it may make a positive diagnosis for a very early condition that, if it had been left alone, may not have done serious harm. The cost of treatment will therefore be wasted.
  • The screening test, the confirmatory tests, and the treatments that will be applied as a result of screening all carry the risk of complications, and the treatment of these complications can be extraordinarily costly.
  • If the patient’s life is saved by the screening test and subsequent therapy, that patient (who is often an Old Fart like DrRich) will persist, for several more years, to soak younger, worthier Americans for Social Security and Medicare payments; and worse, will ultimately develop some other expensive medical problem everyone else will have to pay for.

Q.E.D.

The fact is, the best we can hope for from medical screening tests is that they might save a life here and there, which is hardly a public health victory. But whether they save a few lives or not, they’re inevitably going to cost us a lot of money.

And clearly, from the public health standpoint, a standpoint from which we’re paying for all healthcare collectively from pooled resources (and working hard to deny people the legal right to spend their own money on their own healthcare), it makes no sense to do screening tests.

Screening tests only make sense to the individuals who are at risk for the medical condition being screened, not to the collective.

The New York Times goes on at length to explain how screening for early cancers causes harm and inconvenience for many people in order to help a few. It mentions several of the points in DrRich’s bullet list above. It quotes several public health experts who, shaking their heads sadly, allow as how perhaps the medical profession has “oversold” screening tests in the past decades. These experts lament the fact that the public will need to be re-educated about the limitations and the harm being done by these tests. The Times worries that, perhaps, people will think the new de-emphasis on screening tests is related to healthcare costs, when nothing could be further from the truth.  The worthlessness of screening tests is a new revelation, made clear by recent clinical trials. What can we do but follow the science?

DrRich is not arguing that medical screening tests are invariably a good idea. In fact, he has just given his readers an entire list of reasons they are often not a good idea.

What he is arguing is that the whole framework for our current debate over screening tests is wrong.

The proper way to deal with the imperfections of screening tests is as follows. We should carefully explain to each individual who is a candidate for screening (because they are at risk for the medical condition being screened), all of the risks of embarking on a screening pathway – the potential discomfort, inconvenience, medical risks, and costs of the screening test, of the possible follow-up tests that may be required, and of the treatments that may become necessary if the testing is positive.  The individual can then weigh these negatives against the possibility of failing to discover a treatable disease while it is still treatable. And, taking into account everything that people take into account when making such momentous personal decisions, the individual can do what they believe is right for them. And either decision – to have or not have the test – would be reasonable, rational, and evidence-based – for that individual.

But we are arguing this question as if taking individual preferences into account is not even on the table. We are arguing as if we must make a sweeping decision regarding screening – yes or no – that will apply across the board, to all Americans, regardless of how they would personally weigh the relative risks and benefits.

We are arguing in this way because that’s precisely the approach that Obamacare has codified into law.  Medical decisions from now on will be centralized, and not individualized.  The GOD panelists will determine which decision is best for the collective. And what’s best for the collective is best for us individuals.

But the “screening test debate” graphically illustrates a truth that modern medical ethicists at least implicitly (and often explicitly) deny: What’s best for the collective is NOT always what’s best for the individual. And when we must only make medical decisions collectively, individual Americans will be systematically harmed. And that includes, according to the USPSTF’s own documentation, several thousand women and men each year whose early, currently treatable, but ultimately lethal breast and prostate cancers will no longer be detected early enough to do any good.

DrRich thinks these individuals should be given the opportunity to consider their options regarding medical screening, and make the choice that’s right for them. Progressives – especially the GOD panelists, the public health experts, and most of the American media  – do not.

That’s the debate we should be having.

16 Responses to “Are Medical Screening Tests A Bad Idea?”

  1. GalenOfOld says:

    I noticed that the AMA is now trying (lying?) to the public about how the “doctor-patient” relationship is being protected by the AMA.

    See here — > http://www.ama-assn.org/ama/pub/amawire/2011-october-26/2011-october-26.shtml

    What a load of c#^p!

    BUWHAHAHAHAHAHAHAHAHAHA!

  2. [...] ON THE EARLY-DETECTION FLIPFLOP, over at the Covert Rationing Blog. “It is always risky to speculate on what is actually going on in Ms. Pelosi’s head, but [...]

  3. Roger Zimmerman says:

    There’s one other thing that would/should be explained if we had a rational health care system: the approximate monetary costs of the screening tests and treatment procedures (including procedures for complications), along with the estimated probabilities of all of these events.

    To patients with an insurance contract which covered all of this, it would be useful information (which, they would be free to ignore). To patients with insurance contracts that cover all of it, but would adjust their future premiums based on incurring some of these costs, the patient could take that the odds of that premium increase into consideration. To patients without insurance contracts that covered some or all of this, they could decide if/how they are going to pay for these procedures out of pocket (or if/how to raise the money from charitable organizations, or the like).

    The ability to pay for treatment should certainly be part of an individual’s calculation in deciding whether to undergo such treatment, and they are in the best position to weigh these considerations against the rest of their personal value hierarchy. The proposed increased government takeover of our health care financing system (by individual and insurance company mandates) is designed in part to unburden us of these considerations, and with that, they MUST also unburden us of the treatment choices themselves.

  4. Joe Blow says:

    Letting all those people die of cancer and heart attacks and stroke is going to bend the bejeezus out of the cost curve, just like Ezra Klein and Matt Yglesias said. Just think about all the people the taxpayer won’t have to pay to treat, because they’ll be in the compost bin…

  5. Chris says:

    So Obamacare will cut funds for screening to us low sloping forehead rubes from flyover country. Guess who will continue to get all the screening everyone currently gets? You guessed it, members of congress, federal employees, state employees, and union members. We won’t get the screening, it’ll just be our job to pay for their screening.

  6. Whitehall says:

    Another direction needed is cheaper, more reliable and actionable screening technologies.

    If our centralized planning group thinks this is a dead end and refuses to spend on the R&D necessary, we’ll all be stuck with no marginal screens and no hope of better medical technology.

    While in a free market, innovators who can sense a match between market need and technical advances will rush in to develop and market better screens – which benefits us all.

    Liberal solutions – aren’t.

  7. Without Eyes says:

    I’ve been saying for years, it doesn’t matter whether the recommendations are sound or not. If they are coming from an independent, august professional organisation with a history of straight shooting, people will trust it (are there any more of these?) But if the regulations are coming from a government body of regulators, they will always be suspect, no matter how scientifically sound. People aren’t stupid. They know that the a government body has cost cutting as it’s primary mandate and they suspect, usually accurately, that they will be so desperate to cut costs that they might fudge the science…maybe just a little bit.

  8. Mike says:

    It’s not a “death panel”, it’s an “ignorance panel”!

  9. Marty says:

    Face it, to the elites the rest of us are just so many useless slabs of meat. They would prefer if we all would just die on our 65th birthday, that would take care of the Medicare funding problem.

    If you think I am being harsh, well, I’m just drawing the logical inference from their actions. Do you have a better explanation for what they do and how they do it?

  10. The Man says:

    Welcome to the wonderful world of government health care. I first noticed this phenomenon more than 20 years ago in Canada. As health care demands began to outstrip resources Canadians, up until that time bombarded with advice to “fight cancer with a checkup and a cheque,” were now advised that, in fact, research showed that early diagnosis was a pointless waste of time. The media publicized this research (published almost exclusively in Canadian journals) uncritically and a generation of Canadians were left with the impression that nothing could be done.

    Interestingly enough, we could still watch the old-style public service announcements that continued to be shown on American cable TV channels and of course many Canadians continued to travel to the US for better and more timely medical treatment for all sorts of cancers.

  11. pcb says:

    “DrRich thinks these individuals should be given the opportunity to consider their options regarding medical screening, and make the choice that’s right for them. Progressives – especially the GOD panelists, the public health experts, and most of the American media – do not.”

    the problem is “these individuals” (the ones who would have lives saved by screening) are not known ahead of time. The only way to find them is to screen everyone (or almost everyone). Which puts us right back to the “more trouble than it’s worth” idea.

    • DrRich says:

      pcb,

      You persist in thinking collectively.

      By “these individuals” I am not referring to the ones whose life could be saved by screening. You’re right. We don’t know who they are. I am referring to everyone. That is, every individual should be permitted to weigh the benefits and risks of entering the screening pathway, and make the decision that’s best for them.

      Note that I am not insisting that “society” pay for these decisions. One of the “risks” the individual might need to consider is the financial risk to themselves.

      And Please Also Note: I believe that the healthcare we pay for collectively should be rationed openly (instead of covertly, as we are doing now). But as a corollary to that open rationing of pooled resources, we MUST also allow individuals to spend their own money on any healthcare they decide is in their own best interests, even if the expert panels decide it is not in the collective’s best interest.

      PSA testing and mammograms would be one such example.

      Progressives are openly attempting to prevent the individual prerogative to expend one’s own resources on one’s own well being.

      Rich

  12. Howard Towt says:

    Here’s a link to a blog post I made on the subject and forwarded to the USPSTF folks during their comment period.

    http://www.anti-republicanculture.com/2011/10/psa-politics.html

    Thanks for engaging in some “rousing” of those of us in the rabble. The idea that removing choice from healthcare is a smart path to follow is patently absurd.

  13. richard40 says:

    But I thought all this talk about gov boards, restricting our treatments to save money, and possibly causing us to die as a result, was just propaganda and lies from Palin and those other horrible repubs and libertarians, who opposed Obamacare?

  14. Chris FOM says:

    The ironic part is that screening is something that any true “insurance” should never cover in the first place. Insurance, in its most literal sense, is simply a way for a collective to distribute risk. A group of people pool their money together to pay for something that would be prohibitively expensive for any of them on their own but can easily be covered by a group of funds. As a corollary, however, the actual risk for the incident in question must be low enough that total payments are less than the premiums. For car insurance, an accident is unlikely (most drivers go years without one, those that don’t get dropped) but the cost of a single accident can easily run above $10,000. That’s far above the ability of most people to pay, yet most can afford insurance premiums to keep the cost far more manageable, even though most people will pay more into the system than they take out.

    Screening tests throw all that out the window. The “risk” of needing a screening test is equal to the probability of being in the population considered at risk for the disease (for something like colon cancer, the risk of needing the screening is simply the likelihood that you won’t die before you reach 50). That’s not insurance by any definition, that’s simply taking the costs and spreading them around by having everyone under 50 subsidize the colonoscopies for everyone over 50 Then, when we hit 50 we get our own colonoscopies subsidized. It’s as if my car insurance covered routine oil changes.

    The answer is obvious: all screening tests should be paid for by the patient (with the obvious exception of helping out those who truly can’t afford them). They should NEVER be covered by insurance. The same goes for things like vaccinations. That has the added benefit of removing the artificial price distortions that having a third party payment system creates (the system is incentivized to charge what insurance companies can afford, not the patients themselves). But of course that implies that the collective hasn’t provided all the healthcare we could ever need or even want, and that’s not true, so it can’t be allowed. Therefore we simply have to get rid of screenings altogether.

  15. An MD says:

    Agree 100% w/ Chris FOM

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