Friday, May 9, 2014

Fwd: qotd: Should we pay for screening tests?

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-------- Original Message --------
Subject: qotd: Should we pay for screening tests?
Date: Fri, 9 May 2014 12:54:59 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The New York Times
April 30, 2014
The Problem With Free Health Care
By H. Gilbert Welch

The Affordable Care Act does have its flaws. Here's a big one: It favors
screening over diagnosis.

While the distinction may seem arcane, it has real-world implications.
Screening is what we offer to the well; it's the effort to find
abnormalities in those who do not have signs or symptoms of disease.
Because screening is considered part of preventive care under the
Affordable Care Act, it is provided at no charge.

Diagnosis is what we offer to those who do have signs or symptoms of
disease. Because diagnosis is not preventive care, it is subject to
deductibles and co-payments.

I wish money wasn't such a powerful incentive in medical care. But the
economists are right: Incentives matter. Right now they favor lower risk
patients (those being screened) over higher risk ones (those with signs
and symptoms).

They also encourage a feeding frenzy among providers to recategorize
diagnostic testing as screening. Free screenings were seen as a way to
get people through the door and ideally to find and address problems
before they become more dangerous and expensive.

But in practice, it may not work this way. Some hospitals offer free
screening knowing full well that the costs will be more than made up for
by all the subsequent services required. More testing, false alarms and
overdiagnosis are all part of screening. And if you make it free,
patients are less likely to give proper consideration to these potential
harms — not to mention the potential for a lot of out-of-pocket costs
down the line.

Here's the fix: Eliminate the incentive mismatch between screening and
diagnosis. Treat them equally.

We need people to consider medical care carefully, and that's what cost
sharing is all about.


The New York Times
May 8, 2014
When Cost Deters Care

To the Editor:

H. Gilbert Welch is right to be concerned that patients will forgo
diagnostic mammograms, colonoscopies and other kinds of care for serious
conditions if they aren't free, as "prevention" is under the Affordable
Care Act ("The Problem With Free Health Care," Op-Ed, May 1).

Studies show that even patients who need emergency care for a
potentially serious problem will go without it if they are in a
high-deductible health plan (although this increases their risk of
subsequent hospitalization). And therein lies the problem. While cost
sharing discourages overuse of medical care, it worsens a greater
problem, that of underuse.

In an 11-nation survey by the Commonwealth Fund, more than a third (37
percent) of Americans reported not going to the doctor when sick or not
filling a prescription because of cost, compared with a small percentage
of people in Britain, Sweden and Norway. The difference: They have
single-payer systems in which care is generally free at the point of

Ida Hellander
Chicago, May 2, 2014

The writer is director of health policy and programs for Physicians for
a National Health Program.


The Commonwealth Fund
November 13, 2013
Access, Affordability, and Insurance Complexity Are Often Worse in the
United States Compared to 10 Other Countries
By Cathy Schoen, Robin Osborn, David Squires, and Michelle M. Doty


A 2013 survey conducted in 11 countries finds that U.S. adults are
significantly more likely than their counterparts to forgo health care
because of the cost, to have difficulty paying for care even when they
have insurance, and to deal with time-consuming insurance issues.

USPSTF A and B Recommendations


Comment by Don McCanne

H. Gilbert Welch has been a leading voice in warning us about the costs
and adverse consequences of overdiagnosis. When there is little benefit
but greater potential harm and expense for a given diagnosis, it usually
would be better if that diagnosis had never been made. This is
especially true when a screening test is done on a healthy individual if
it leads to a diagnosis that will be of no help but could result in harm
to the patient.

When should screening tests be done? The decisions should be made by
patients after their health care professionals provide them with
adequate information regarding the potential benefits and adverse
consequences of the screening procedures. That advice should reflect the
latest information available from sources such as the U.S. Preventive
Services Task Force (USPSTF). In fact, the Affordable Care Act
specifically covers, without charge, level A and B preventive service
recommendations of the USPSTF. (Link above - USPSTF recommendations are
updated as new information becomes available.)

Dr. Welch would add one other consideration. He would require patients
to pay a portion of the costs for the screening tests just as they would
for diagnostic testing used to evaluate specific symptoms or signs. It
is well known that if people have to pay for screening tests that they
should have, many will decline them simply because of the expense. This
can result in adverse health outcomes or even death. If a screening test
warrants an A or B USPSTF rating, its benefits do outweigh the potential
harm, and it should be offered to the patient without placing it behind
a "paywall" (deductible, coinsurance or copayment).

Dr. Welch has it backwards. We should eliminate the incentive mismatch
between screening and diagnosis, but we should do that by removing the
paywalls for diagnostic and therapeutic services rather than creating
new ones for preventive screening.

PNHP's director of health policy, Ida Hellander, has it exactly right.
Rather than overuse, we have a much greater problem with underuse of
beneficial health care services, and cost-sharing paywalls worsen that

The Commonwealth Fund study that Dr. Hellander cites shows that the
United States has a much greater cost-related access problem than do the
other ten wealthy nations studied, yet those nations spend far less on
total health care than we do, without the necessity of erecting these
paywall financial barriers to care.

We can thank Dr. Welch for his great work in explaining to us the
potential negative consequences of screening tests. With this
information we can better inform the patient who has to make the
decision on undergoing screening. But we can also thank Dr. Hellander
for her great work on explaining to us why health care should be based
on patient need rather than on the patient's ability to pay.

Quite simply, patients should have the care that medical science
dictates they should have, if they want it, but not denied that care
because they feel they cannot afford it.

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