American medicine is poised for an expanded conflict over the assumption and consequences of risk in medical care.
American medicine is poised for an expanded conflict over the assumption and consequences of risk in medical care. This conflict has developed over the screening of disease, and the premise that early intervention and treatment reduce morbidity and mortality. The proactive approach to medical care exemplified by screening and early intervention has resulted in medical innovations, and has significantly improved outcomes for the most common health problems in America-cancer and cardiovascular disease. In oncology, the early diagnosis and treatment of cancer has allowed for organ-sparing multimodality therapies that have enhanced quality of life (QOL) and other health outcomes.
In recent years, medical care, as promulgated by the US Preventive Services Task Force (USPSTF), has become more passive and reactive to disease. Instead of enhancing QOL by preventing or curing a life-threatening disease, the screening and early treatment of the most common cancers is now thought to cause distress and complications from unnecessary care. While proponents of both approaches argue that their position is centered on the well-being of the individual, the focus of concern has shifted from patients with disease to the larger group of patients without disease.
This shift in concern is a critical political step-because it indirectly reduces healthcare costs. While claiming concern for the individual without disease who is unnecessarily distressed and risks morbidity from a diagnostic or therapeutic intervention, this new approach allows the Centers for Medicare and Medicaid Services, the Patient-Centered Outcomes Research Institute, and other agencies to be compliant with their stated policy of not considering cost in clinical recommendations or coverage determinations. However, by changing the standards of care, healthcare costs are indirectly reduced through decreased utilization. This is especially significant for cancer screening procedures that target large populations.
The Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) decision on low-dose CT lung cancer screening is the latest in a series of decisions that have changed widely accepted guidelines on cancer screening and shifted them in a new direction. In November 2009, in conflict with every existing guideline, the USPSTF set off a political firestorm when it recommended against routine screening mammography in women 40 to 49 years of age, stating that the decision to start regular screening mammography should take into account “the patient’s values regarding specific benefits and harms.” In 2012, after noting that 70% of deaths due to prostate cancer occur after age 75, the USPSTF recommended against PSA-based screening for prostate cancer and for watchful waiting as a therapeutic strategy.
Unlike the USPSTF, which is concerned with all age groups, MEDCAC is concerned only with the Medicare-aged population. While the percentage of smokers in all age groups under 65 (20%) is about twice that in the Medicare population (10%), the vast majority of lung cancers occur in persons aged 65 or older due to the latency in the development of the disease.[3,4]
With exploding national budget deficits and the acknowledgment that the Affordable Care Act will cost far more than projected, policymakers are keen to rein in healthcare costs on those who utilize healthcare most. In 2009, almost half of all healthcare spending ($623 billion) was consumed by 5% of the population, and Medicare recipients accounted for 38.2% of that group.
As screening for prostate and lung cancer becomes more restricted, the demographics of cancer stage at diagnosis and mortality rates will need to be closely monitored. With reduced screening, patients now assume an increased risk of delayed cancer diagnosis, morbidity, and death. Despite US Food and Drug Administration approval of both PSA screening for prostate cancer and low-dose CT screening for lung cancer, the USPSTF and MEDCAC now consider the risk of distress and potential complications from these cancer-screening procedures to be greater than the potential risk of cancer itself. Avoided in the discussion, however, is the benefit to the federal budget from restrictions in cancer screening and care.
Financial Disclosure:The author has no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.
1.GUS Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2009;151:716-26.
2. Moyer VA; US Preventive Services Task Force. Screening for Prostate Cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120-34.
3. National Center for Health Statistics; Centers for Disease Control, US Department of Health and Human Services. Health, United States, 2013, with special feature on prescription drugs. Hyattsville, MD. 2014.
4. Centers for Disease Control. Lung cancer risk by age. Available from: http://www.cdc.gov/cancer/lung/statistics/age.htm. Accessed October 22, 2014.
5. National Institute for Health Care Management. The concentration of health care spending. NIHCM Foundation Data Brief. July 2012. Available from: http://www.nihcm.org/pdf/DataBrief3%20Final.pdf. Accessed October 22, 2014.