The dan­gers of high-end health care

Baltimore Sun - - COMMENTARY - By Adam Cifu and James Woodruff Drs. Adam Cifu (adam­cifu@uchicago.edu) and James N. Woodruff ( jwoodruf@medicine.bsd.uchicago.edu) are pro­fes­sors of medicine at the Univer­sity of Chicago.

Econ­o­mists love to praise the freemar­ket ben­e­fits of first-class air travel. Trav­el­ers of means pay more for early board­ing, a com­fort­able seat, a drink be­fore econ­omy pas­sen­gers board and a few other niceties. The price these trav­el­ers pay (or, more ac­cu­rately, the price paid by those bear­ing the cost of their tick­ets) helps sub­si­dize the prices paid by econ­omy pas­sen­gers, and ev­ery­one gets to his or her des­ti­na­tion. If the pre­mium paid by first-class pas­sen­gers also bought an in­creased like­li­hood of phys­i­cal harm and un­war­ranted anx­i­ety, this would be an ir­ra­tional model — one that re­sem­bles hos­pi­tal ex­ec­u­tive health programs.

Ex­ec­u­tive health programs are com­mon at aca­demic med­i­cal cen­ters across the United States. Each of the coun­try’s 10 largest metropoli­tan ar­eas has at least one such pro­gram, and most have many more. Four of the hos­pi­tals in the Bal­ti­more/ Washington area of­fer such programs, in­clud­ing Johns Hop­kins, which de­scribes its pro­gram as giv­ing “busy ex­ec­u­tives an ef­fi­cient way to re­ceive a con­fi­den­tial, com­pre­hen­sive, head-to-toe health as­sess­ment from one of the world’s lead­ing in­sti­tu­tions” at their con­ve­nience.

The programs gen­er­ally charge a set fee for a com­pre­hen­sive visit in an el­e­gant set­ting with sched­ul­ing that al­lows con­sul­ta­tions with mul­ti­ple physi­cians and af­fil­i­ated health-care pro­fes­sion­als, test­ing and dis­cus­sion of re­sults all in a sin­gle visit. They of­fer per­son­al­ized care or­ga­nized around a per­son’s sched­ule and are mar­keted to­ward pro­fes­sion­als and their em­ploy­ers.

The ben­e­fits of these programs to pa­tients and in­sti­tu­tions are ob­vi­ous. Pa­tients gen­er­ally re­ceive high-level care with­out the sched­ul­ing hassles com­mon at aca­demic cen­ters. For the med­i­cal cen­ters, ex­ec­u­tive health programs gen­er­ate in­come — di­rectly, in the fees they charge, and in­di­rectly, by at­tract­ing well-in­sured pa­tients who may even­tu­ally seek to con­tinue their care at the in­sti­tu­tion or even be­come bene­fac­tors. Med­i­cal cen­ters use the in­come gen­er­ated by ex­ec­u­tive health programs to sup­port less well­funded as­pects of a med­i­cal cen­ter’s mis­sion: research, ed­u­ca­tion and the care of the unin­sured or un­der­in­sured pa­tients. So what is the harm? There is com­pe­ti­tion be­tween med­i­cal cen­ters for the rel­a­tively small num­ber of peo­ple and com­pa­nies will­ing to pay for this ser­vice. Be­cause ba­sic health main­te­nance ser­vices are stan­dard­ized and far from com­plex, med­i­cal cen­ters com­pete by of­fer­ing what seems like bet­ter care. In re­al­ity, the care they of­fer is not bet­ter care, it is just more care — care that of­fers no proven ben­e­fit but very of­ten risk of harm.

Ex­ec­u­tive health sites we re­viewed list pro­ce­dures such as screen­ing car­diac stress tests, skin and prostate can­cer screen­ing, pe­riph­eral artery dis­ease screen­ing and screen­ing for carotid artery steno­sis. Of these five prac­tices, the United States Pre­ven­tive Ser­vices Task Force (USPSTF) rec­om­mends against three of them and, be­cause of in­suf­fi­cient ev­i­dence, can­not make rec­om­men­da­tions about the other two.

The USPSTF is an in­de­pen­dent, vol­un­teer panel of na­tional ex­perts in dis­ease preven­tion and ev­i­dence-based medicine. It is the most re­spected ar­biter of pre­ven­tive and screen­ing in­ter­ven­tions in the United States. When the USPSTF chooses not to rec­om­mend an in­ter­ven­tion, it does so be­cause there is ei­ther no ev­i­dence that the in­ter­ven­tion is ef­fec­tive or be­cause there is ev­i­dence of fu­til­ity or ac­tual harm. The USPSTF does not con­sider costs when mak­ing rec­om­men­da­tions; it does not with­hold a rec­om­men­da­tion be­cause the cost of the in­ter­ven­tion is too great.

What are the prob­lems with of­fer­ing un­proven, and thus in­ap­pro­pri­ate, tests? Ex­cess care fre­quently leads to find­ings of un­cer­tain sig­nif­i­cance. These find­ings lead to pa­tient anx­i­ety and falsely la­bel a pre­vi­ously healthy per­son as ill. Fol­low-up of these find­ings re­quires un­nec­es­sary eval­u­a­tions and, some­times, treat­ments. Phys­i­cal harm may oc­cur dur­ing these eval­u­a­tions. Even when no phys­i­cal harm is done, un­nec­es­sary costs are ac­crued. These costs are usu­ally paid for by pri­vate or gov­ern­ment in­sur­ance. Treat­ment of in­ci­den­tal find­ings has no proven ben­e­fit.

If you doubt that un­nec­es­sary eval­u­a­tions can do harm, ask any doc­tor who­has prac­ticed in the last two decades; you will soon be awash in anec­dotes of pa­tients suf­fer­ing con­se­quences of a “rou­tine” blood test or x-ray. Dr. Michael B. Roth­berg, in a now famous ar­ti­cle pub­lished in JAMA in 2014 en­ti­tled “The $50,000 Phys­i­cal,” re­counts the har­row­ing tale of a pa­tient who ran up a $50,000 bill and re­quired a trans­fu­sion of 10 units of blood, among other things, as the con­se­quence of an ill-ad­vised phys­i­cal exam.

Ex­ec­u­tive health programs have con­sid­er­able po­ten­tial. They of­fer busy peo­ple of means a way to ob­tain care in a com­fort­able set­ting that also fits into their sched­ule. By al­low­ing peo­ple to ad­dress chronic is­sues or to ac­cess war­ranted screen­ing that they have been too busy to pur­sue, they may even im­prove health out­comes. They also en­able aca­demic med­i­cal cen­ters to ben­e­fit fi­nan­cially from what they do best, pro­vid­ing ex­cel­lent, ev­i­dence-based care.

To­day’s ex­ec­u­tive health programs, how­ever, tempt med­i­cal cen­ters to of­fer a du­bi­ous prod­uct. Peo­ple who en­roll in these programs de­serve clar­ity about what they are pay­ing for — a nice wait­ing room, pa­tient cen­tered sched­ul­ing, care that is more at­ten­tive than to­day’s norm — and, very of­ten, ex­pen­sive, un­proven and po­ten­tially harm­ful care.

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