It’s Not Just About Costly Drugs – It’s Testing, Too

On the stump, many of the candidates are railing against skyrocketing drug costs. They promise at campaign rallies at the top of their lungs to “Bring down the cost of drugs.” This blog, however, claims that it’s not only about costly drugs.

It’s the whole system that is rigged and has high costs baked into it – double the costs in other industrialized countries across the board.

Case in point is medical testing.

Excessive Testing at Scale

Two Harvard experts sounded the alarm on “excessive testing at scale” in last month’s AMA Journal.

Here are the highlights:

… aggressive testing may arise when [tests] yield financial benefit to drug and device manufacturers, procedure-based specialties, hospitals, or laboratory testing services or is increasingly requested by patients. Excessive testing can also lead to costly and harmful care, including false-positive results, overdiagnoses, and unnecessary treatments. Economic pressures, obfuscated intentionally or inadvertently, can drive increased use of [testing], a phenomenon that could be termed “biomarkup.”

Please see “Diminishing Marginal Benefit” for my take on ever-increased testing and treatment.

Drs. Mandl and Manrai cite excessive testing potentially being driven by direct-to-consumer promotion, artificial-intelligence algorithms (replacing physician judgment), wearables, and genomics.

They cite two recent examples.

To promote its osteoporosis drug alendronate sodium (Fosamax), Merck helped developed bone densitometry and establish the Bone Measurement Institute, a not-for-profit company, that worked to increase the number of densitometers and achieve an optimal price point for the test…  The American Pain Society, with funding from Purdue Pharmaceuticals, make of OxyContin, established and trademarked the “Pain: the Fifth Vital Sign” slogan and successfully promoted more pain treatment.

They conclude

A health care system delivering value must use testing and services judiciously. Processes are needed to ensure that advocacy for [testing] provides value and not just profit… and support transformation toward a safer, cost-effective health care system. Policy makers, guideline producers, payers, regulators, clinicians and patients require knowledge to recognize paid advocacy… around lucrative tests…

Patients have benefited from advances in [testing] and selection. So too have drug and device manufacturers, procedure-based specialties, hospitals, laboratory testing services, and patent holders. In the 21^stcentury, as the number of potential biomarkers expands exponentially, it will be important to ensure a system that benefits patients and improves their health.

Conclusion:  I agree. Excessive tests – and the wild-goose-chases that they may unleash – can drive up costs without giving any benefit. And may actually cause harm or needless anxiety. Be careful out there!

 

One More Example of Costly Test Misuse: Lung CT Scans for Smokers

Up until 2011, no study of x-rays or CT scans had shown any success in detecting and successfully curing lung cancer. Then in 2013 the National Lung Screening Trial result showed that for every 320 heavy smokers screened with a low-dose CT scan, 1 lung cancer death could be prevented.  But only if

• The patient cooperated with further testing (needed by 86 of each 320 screened)
• The patient agreed to further CT’s (needed by 63 of the 320), invasive bronchoscopies (needed by 10), or invasive biopsies (needed by 5)
• The patient agreed to lung lobe removal surgery if recommended (needed by 9 of the 320)
• The patient understood that among those 9 with the surgery, 1 would be a cancer cure, 4 would still die from lung cancer, and 4 would be found to have been “false alarms”
• The patient understood that, by among a comparison group of 320 without the CT scan 5 would die of lung cancer, a net result of 1 cancer death prevented by the CT scan screening.

In 2015, Medicare approved this CT scan screening protocol for more general use. But Medicare required that patients should be informed of the pros, cons, and odds beforehand.  Experts advised that the CT scans should be done only at centers “where explicit formal collaboration exists between radiologists, pulmonary specialists, and thoracic surgeons” able to provide follow-through care of abnormal findings.

However, a new study in the January 2019 AMA Journal indicates that only 9% of patients who had the CT scan screen in 2016 actually had a visit to discuss the pros and cons beforehand.  I conclude that a CT scan without the the patient’s agreement beforehand on follow-through is a boon to radiologists, but a waste of money, and is a potential cause of unnecessary harm and anxiety.

The same study showed when patients did have discussions of pros and cons, 39% decided not to get the scans, presumably because they decided that harms outweighed the benefits to them, when they got the facts.

Conclusion:  Testing that is misused provides no value and simply adds to overall cost.

Now, Take Action

 

Image Credit

Title:  Medical Laboratory Scientist at US NIH

By: National Institutes of Health

URL:  https://commons.wikimedia.org/wiki/File:Medical_Laboratory_Scientist_US_NIH.jpg