Mak­ing pre­ven­tive care more at­trac­tive could boost test­ing

Mak­ing pro­ce­dures less dis­tress­ing, of­fer­ing un­bi­ased info could boost test­ing

Modern Healthcare - - NEWS - Emily Fried­man

As hap­pens oc­ca­sion­ally, preven­tion has be­come a buzz­word in health­care—at least tem­po­rar­ily. The Pa­tient Pro­tec­tion and Af­ford­able Care Act in­cludes sev­eral pro­vi­sions boost­ing pre­ven­tive health ser­vices. Em­ploy­ers, in­sur­ers and providers say they want to em­pha­size preven­tion. Emerg­ing de­liv­ery and pay­ment struc­tures—ac­count­able care or­ga­ni­za­tions, pa­tient-cen­tered med­i­cal homes and bundling of pay­ments—pro­vide pow­er­ful in­cen­tives to stop ex­pen­sive dis­eases be­fore they start.

Three re­cent stud­ies il­lus­trate the com­plex­i­ties of preven­tion. In Jan­uary, the Agency for Health­care Re­search and Qual­ity re­ported that 1% of pa­tients rep­re­sented 20.2% of all health­care ex­pen­di­tures in 2008; 5% of pa­tients rep­re­sented 38% of the to­tal. On Feb. 23, a New Eng­land Jour­nal of Medicine study con­firmed that colonoscopy re­duces col­orec­tal can­cer deaths and is more ef­fec­tive than sig­moi­doscopy or stool test­ing, es­pe­cially in de­tect­ing pre­can­cer­ous polyps. But an­other study in that is­sue found that pa­tients were more will­ing to un­dergo stool test­ing than colonoscopy.

It doesn’t take a rocket sci­en­tist to fig­ure out why. Colonoscopy prepa­ra­tion in­volves con­sum­ing only clear liq­uids for at least a day and in­gest­ing un­pleas­ant-tast­ing lax­a­tives that leave pa­tients com­muning with na­ture in the bathroom for hours. As Dr. Sid­ney Wi­nawer, one of the au­thors of the colonoscopy ef­fec­tive­ness study, said, “Sure, it’s a pain in the neck. Peo­ple com­plain to me all the time, ‘It’s hor­ri­ble. It’s ter­ri­ble.’ ”

It is not sur­pris­ing that AHRQ found that in 2008, only 60% of white Amer­i­cans and 55% of African-amer­i­cans over 50 had been screened for col­orec­tal can­cer; only 44% of Lati­nos and 37% of Na­tive Amer­i­cans had.

The same story can be told about mam­mo­grams, prostate can­cer screen­ing, en­doscopy and other pre­ven­tive pro­ce­dures.

Why is it so dif­fi­cult to get peo­ple to put up with some de­gree of dis­com­fort or in­con­ve­nience when it could save their lives?

One rea­son is pa­tients’ re­luc­tance to sub­mit to what they be­lieve is an aw­ful ex­pe­ri­ence. Women don’t en­joy hav­ing their breasts mashed in a ma­chine, and men don’t en­joy hav­ing their gen­i­tals dig­i­tally ex­am­ined. Be­ing told that a colonoscopy or en­doscopy is equiv­a­lent to be­ing burned at the stake pro­vides a

We should be con­sid­er­ing al­ter­na­tives on both the pay­ment and de­liv­ery sides.

per­fect ex­cuse for some­one who didn’t want to un­dergo the pro­ce­dure in the first place.

In ad­di­tion, many pa­tients fear what screen­ing might re­veal. And some im­mi­grants, peo­ple who speak lit­tle or no English and those with poor health lit­er­acy may be ig­no­rant of the value of these tests.

Also, ac­cess to screen­ing can be con­strained for Med­i­caid and even Medi­care ben­e­fi­cia­ries be­cause of provider re­luc­tance to ac­cept them. And that’s as­sum­ing the Med­i­caid pro­gram cov­ers all pre­ven­tive ser­vices.

For pa­tients with­out in­sur­ance, ac­cess is even more dif­fi­cult. Tests are not cheap, and there are long waits to get them for free. The Com­mon­wealth Fund found that in 2011, peo­ple who were unin­sured at least part of the year were less likely to un­dergo blood pres­sure test­ing (52% vs. 80% for in­sured per­sons), choles­terol checks (35% vs. 64%), Pap tests (49% vs. 66%), mam­mo­grams (32% vs. 66%) and colon can­cer screen­ing (10% vs. 50%). How can the sit­u­a­tion be im­proved? Cov­er­age for preven­tion should be broader. There is both op­por­tu­nity and threat in the fed­eral gov­ern­ment’s decision to give states lat­i­tude in con­fig­ur­ing “es­sen­tial health ben­e­fits” un­der re­form. If Med­i­caid ben­e­fits de­sign is any in­di­ca­tion, many states could ig­nore some pre­ven­tive ser­vices. The fed­eral com­mit­ment ap­pears am­biva­lent as well; in or­der to pay for post­pon­ing the loom­ing Medi­care fee re­duc­tion for physi­cians, Congress cut $5 bil­lion from the ACA’S preven­tion fund.

The op­por­tu­nity is that if all pay­ers are re­quired to cover proven pre­ven­tive ser­vices, uti­liza­tion should in­crease. In­deed, cov­er­age for some ser­vices should prob­a­bly be man­dated for ev­ery­one, even the oth­er­wise unin­sured. In­cen­tives for providers to in­crease out­reach wouldn’t hurt, ei­ther.

Also, the best way to counter the hor­ror sto­ries is to make un­bi­ased, un­der­stand­able in­for­ma­tion widely avail­able.

A longer-term so­lu­tion would be to fa­mil­iar­ize chil­dren with pre­ven­tive ser­vices, so that when they are grown, preven­tion will just be part of life. Also, provider, phar­ma­ceu­ti­cal and med­i­cal de­vice groups should try to find eas­ier ways to check for col­orec­tal can­cer than mak­ing pa­tients con­sume nasty stuff and spend hours on the toi­let, and then deny­ing them food and water. There are count­less jokes about how mam­mo­grams would be de­signed if men were sub­ject to them. Re­con­fig­ur­ing these pro­ce­dures to make them less ob­nox­ious could make a huge dif­fer­ence.

Speak­ing of his study on colonoscopy, Wi­nawer, con­ced­ing that some as­pects of the pro­ce­dure are less than en­chant­ing, added, “But look at the al­ter­na­tive.” We should be con­sid­er­ing al­ter­na­tives on both the pay­ment and de­liv­ery sides.

True preven­tion al­most al­ways means swim­ming up­stream. It’s dif­fi­cult to push ex­er­cise and low-fat, low-salt di­ets in a so­ci­ety in which peo­ple are chained to their com­put­ers all day, fast food is ubiq­ui­tous, and a guy can star in a tele­vi­sion se­ries by eat­ing his way through the most gi­gan­tic res­tau­rant meals imag­in­able. Get­ting ev­ery­one screened for com­mon can­cers, di­a­betes and other con­di­tions is a tall or­der. But if we make the com­mit­ment, it could be the most ef­fec­tive means yet of bend­ing the cost curve.

Be­sides, the life you save may be your own.

Emily Fried­man is an in­de­pen­dent health pol­icy and ethics an­a­lyst based in Chicago.

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