Mailbag: Screenings useful in cancer fight

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Our local newspaper received a letter in response to our column about why insurance Companies are reluctant to cover preventive care.

Our main point in the column was that preventive care might make great medicine, but it doesn’t save insurance companies or the government health care systems money. It is an expense. We wrote the column because many of those in favor of the Affordable Care Act (ACA) tried to argue that paying for more preventive care would save money by preventing people from getting costly diseases. Our primary point was to debunk that claim. We used colonoscopies as our example, and receives a reply from Dr. David H. Balaban of the Charlottesville Gastroenterology Associates.

I’m reprinting the letter interspersed with my comments.

Screenings useful in cancer fight

David John Marotta and Megan Russell argue that screening tests like colonoscopy “offer no medical benefit” and should not be paid for through health insurance, which should cover only “catastrophic, extremely expensive events” (“Preventive care tests raise health care costs,” The Daily Progress Aug. 17).

False.

That is not what we argued.

Let’s put the quote that screening tests “offer no medical benefit back in context.” What we wrote is: “A screening test looks for a disease when the patient has no symptoms. And because of the lack of symptoms, nearly all of these tests offer no medical benefit.”

Most offer no medical benefit because the patient doesn’t have the disease. And the cost of all the tests that find nothing has to be weighed against any savings in the cost of treatment of those that do find something.

As a result of the ACA you can now get the follow preventive care screenings without having to pay a copayment or co-insurance or meet your deductible: Abdominal Aortic Aneurysm screening, Alcohol Misuse, Aspirin use, Blood Pressure screening, Cholesterol screening,  Colorectal Cancer screening, Depression screening, Type 2 Diabetes screening, Diet counseling, HIV screening, Immunization vaccines (Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella), Obesity screening and counseling,  Sexually Transmitted Infection (STI) prevention,  Tobacco Use screening, cessation interventions for tobacco users, and Syphilis screening. There are even longer lists for women and children.

If you were to screen the entire country, nearly all of the tests you performed would offer no medical benefit since most patients don’t have any of these health care issues. It would also be tremendously expensive. And therefore, in order for these tests to *save* insurance companies money, the expense of these tests has to be compensated by preventing costly care later. We made this context clear as we continued:

“For a screening test to save money, the costs must be very low, the benefit long lasting and the potential for side effects unlikely.”

“It is easiest to make a case for vaccination. The costs are low, the benefit is relatively permanent and the potential for side effects, although devastating to those that experience them, are extremely unlikely.”

Again, we were asking if such screening saved insurance companies money, and the answer is, “No.” We made it clear that we were not suggesting anything about the medical benefits of a colonoscopy when we wrote:

“We are not suggesting you avoid a colonoscopy. We are not qualified to assess the medical risks and benefits for your specific situation. Colonoscopies are just one of several potential colon cancer screening methods. Each one has its own risks and benefits.”

The Dr. Balaban’s letter continued:

Colon cancer is the second-leading cause of cancer-related death in the U.S. It is also one of the few cancers that can be prevented with proper screening. Thanks to the late Sen. Emily Couric, D-Charlottesville, Virginia was the first state to mandate insurance coverage for colon cancer screening. Colonoscopy can detect cancer at an early stage, when it is curable, or in a precursor stage, when it is preventable.

Why is forcing 20-year old patients to pay for an insurance with free colon cancer screening that they do not want and are not going to use something which is touted as virtuous?

Limiting someone’s choice of insurance is not freedom.

And forcing insurance companies to pay for such screenings with zero co-pay, zero co-insurance, and zero deductible drives up the cost of colonoscopies.

The high cost of colonoscopies was one of the factors cited for why we needed the ACA. And yet it is legislation like the ACA which have driven up their costs.

Since insurance is now paying for every colonoscopy, groups such as the Charlottesville Gastroenterology Associates don’t even bother publishing what they will cost on their website. If the cost is $655 or $9,000 patients don’t care. In fact if the $9,000 is even slightly better they will send their business there. There is no negative feedback to the healthcare buffet.

The columnists cite a 2012 New England Journal study and argue that a 53 percent reduction in colorectal cancer attributable to colonoscopic polyp removal is too costly a venture.

So what is the cost of a life saved? Although the authors contend that “screening tests rarely, if ever, save money,” the Centers for Disease Preventions report that colonoscopy is just such a test, with an estimated life-year cost (a measure of disease burden and quality of life) of $11,890 to $29,725, below the accepted $50,000 threshold.

At this point Dr. Balaban contradicts himself and makes our point for us.

If screening tests *saved* money the cost would be negative. You can argue that they save lives, but you can’t argue that they save money. The more colonoscopies you do the more you drive up the cost of health care and health care insurance. You may produce better outcomes, but you will not produce lower costs.

If everyone in the United States got their free colonoscopy at an average cost of $1,185 it would cost 10% of the annual U.S. healthcare spending. This might be good for Dr. Balaban and the Charlottesville Gastroenterology Associates, but it is not good for the 20-year old who sees the cost of his health insurance skyrocket.

And the only way the Charlottesville Gastroenterology Associates would have to curb the increased demand would be to raise their prices ten-fold.

No screening test is perfect. Regrettably, however, the columnists mislead when they report colonoscopy accuracy. Colonoscopy rarely misses existing cancers; but interval cancers, which develop before the next colonoscopy is due, may occur. As we learn more about the biology of this disease and as the technology advances, efforts to detect and prevent this type of cancer will improve.

In the article we wrote, “As many as 6% of colonoscopies on patients with existing colorectal cancer fail to find the disease. They also fail to find adenomas larger than 1 cm that become cancer about 15% of the time.” Dr. Balaban calls this misleading, but never cites a different percentage.

Our citation was one of a series of position statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared the document. I don’t know why Dr. Balaban calls these statistics misleading. We cited them to show that such failures add to the cost without adding to the benefit. Inverval cancers which develop before the next colonoscopy have the same economic effect.

The authors also suggest that colonoscopy is a dangerous procedure and that sedation is both costly and unnecessary. For most patients, eliminating sedation would be an unnecessary deterrent.

Europe and Asia lower the costs of a colonoscopy by eliminating sedation. This makes the economics of colonoscopies less costly. And since an adverse reaction to sedation is one of the most common complications, sedation adds to the cost in two ways.

Finally, since insurance is required to include sedation for no extra charge, everyone in the United States has sedation even if the costs would not be worth it if they were paying for it themselves. Hence a third way that sedation adds to the cost is because it drives up insurance costs as they have to factor in 100% of patients having the extra charge of sedation.

The authors also overstate the risk of complications requiring hospitalization after colonoscopy; the U.S. Preventive Services Task Force estimates that serious complications occur at a rate of 1 in 400 procedures, primarily in the very elderly.

We wrote: “Complications like these put 1 in 200 patients in the hospital.”

I will concede that Dr. Balaban can cite a study showing 1 in 400 have to be hospitalized *immediately* as a result of the procedure if he will concede other studies show a 1 in a 100 that are hospitalized within 30 days of the procedure as a result of the procedure. I assume that the study we cited falls somewhere in the middle.

Even if the number is just 1 in 400, if  the entire U.S. population were to get their free colonoscopies, there would be nearly 800,000 hospitalized patients we would have to credit as increasing the cost of the procedure.

Perhaps the columnists should ask anyone with cancer whether his diagnosis was a catastrophic or expensive event and whether preventing that cancer would have been cost-effective.

Again, it might very well be cost effective for you to pay for your own colonoscopy.

But it will never be cost effective for you to pay for my colonoscopy.

Nor is it cost effective for government to mandate free colonoscopies in an attempt to make health care more affordable.

I will let Dr. Balaban have the last word.

No patient should die from colon cancer due to fear of screening. Although colonoscopy remains the gold standard, newer screening tests, like a recently approved stool test, offer hope that screening will evolve to include a variety of sensitive, low-risk and cost-effective options for patients who would otherwise avoid screening out of fear alone.

Dr. David H. Balaban

Charlottesville

This letter also was written by Dr. Diego A. Gomez, Dr. Byrd S. Leavell Jr., Dr. Michael J. Oblinger and Dr. Daniel J. Pambianco. Along with Dr. Balaban, they are physicians in practice at Charlottesville Gastroenterology Associates.

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David John Marotta is the Founder and President of Marotta Wealth Management. He played for the State Department chess team at age 11, graduated from Stanford, taught Computer and Information Science, and still loves math and strategy games. Favorite number: e (2.7182818...)