Health for life

Testing for hidden early lung cancer

Remember this article on screening for lung cancer? 

More than 54,000 former and current tobacco users who looked like they were free of cancer were randomly assigned to a yearly cheapo chest x-ray vs. a yearly pricey low-radiation-dose CAT scan. Over 5 to 7 years of follow-up, the CAT scan was better at picking up early lung cancer (119 cases) which translated into a small but statistically significant survival advantage of 62 lives saved per 100,000 patient years.

Does this mean that Medicare, Medicaid and all commercial insurers should "cover" a baseline and yearly follow-up screening CAT scan for tobacco smokers at risk for lung cancer?  According to actuary Bruce Pyenson and colleagues writing in the latest issue of Health Affairs, the answer may be yes.

The Disease Management Care Blog thinks the answer may still be no. 

Is it being a heartless curmudgeon?  Read on and decide for yourself.......

In the Health Affairs article, the authors assumed current and former tobacco smokers comprise about 30% of persons aged 50-64 years.  They further assumed that about 50% of persons at risk would agree to the CAT screening exam.  Based on prior studies, they estimated that 21% of the baseline scans and 7% of the follow-up yearly scans would require additional testing and figured lung cancers would be present in 0.6% and 0.2% of the baseline and follow-up scans. They used a fee rate of $247 per screening for both the scan and included the cost of a counseling session on smoking cessation.  

Spread over a population, the cost of the screening would amount to 76 cents per member per month (PMPM). On a nationwide basis, there would be 130,000 additional lung cancer survivors.  The cost per life-year saved in 2012 dollars would range between $11,708 and $26,016.  To put things in perspective, it costs more per life-year saved to use current screening approaches to cervical cancer with pap smears (more than $50,000), colon cancer with colonoscopies ($18,000 to $29,000) and mammography ($31,000 to $51,000).

Much of the high costs of these other cancer screening procedures are the result of more persons being eligible for the testing.  In the Health Affairs study, the only persons getting the scan are smokers who are at high risk.

What did the DMCB learn?

One important lesson in this study is that cancer screening is not free.  Its too easy to assume that the early detection provided by mammography, colonoscopies and pap smears pays for itself.  Thats simply not true.  What is true is that cancer screening is good value, but itll still cost you for each life saved.

The second lesson is that good value still represents incremental cost.  As a result, the 76 cents PMPM is in addition to the money already being spent by health insurers.  While the extra pennies doesnt seem like a lot of money, the health insurance dollar is comprised of coverage of similarly priced goods and services, and all those pennies are continuing to add up.  The DMCB thinks were getting to the point where the U.S. would need to ask what coverage of which service should be cut to pay for lung cancer screening.

Both of these issues make it unlikely that insurers will willingly include coverage of screening CAT scans in their health insurer benefit.  They can also argue that it would be highly unusual to decide to cover a new screening procedure based on a single study that hasnt even been reviewed yet by the U.S. Preventive Health Services Task Force.

Last but not least, the DMCB is willing to bet that there wont be much consumer demand for coverage by insurers because of bias against the victims of tobacco-associated illnesses as well as the argument that smokers should self-pay based on the comparative cost of a years worth of cigarettes.

It remains to be seen if, under their ability to define a minimum insurance benefit as part of the Affordable Care Act, the Feds will require lung cancer screening.

Stay tuned!

Image from Wikipedia

Diabetes education is effective, but sure doesnt pay ... at least for providers. Ask Dr. Bernstein (at right), former president of the American Diabetes Association, and director of one of 3 hospital-based diabetes centers in New York City that recently closed.

Dr. Jerry Bernsteins diabetes clinic at Manhattans Beth Israel Medical Center was reporting a 60% success rate for patients controlling their blood glucose - when news came from the hospitals president, "Jerry, ... were going to have to close your program."

In one of a series of articles the New York Times is running on diabetes, the plight of prevention, and the demise of Dr. Bernsteins clinic, is explored:

"[These clinics] did not shut down because they had failed their patients. They closed because they had failed to make money. They were victims of the byzantine world of American health care, in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications."

To drive home the point:

"Not surprising, as the epidemic of Type 2 diabetes has grown, more than 100 dialysis centers have opened in the city."

The article ran in the New York Times yesterday. You can read it at:
In the Treatment of Diabetes, Success Often Does Not Pay

According to the Kaiser Foundation, health care costs are continuing to go up. Assuming Uncle Sam is doing everything he can to "increase efficiency" and "reduce waste," what are the options that can quickly control costs?

Its simple: leverage the insurance companies or the providers or both.

1. Tell the insurance companies what they can charge: While the ability of the Feds to regulate insurance remains murky, the Affordable Care Act enables CMS to require that insurance companies "justify" a premium increase of 10% and keep their administrative costs below 15%.

What is less appreciated is that the Medicare premium support plan being championed by Republican Paul Ryan is a variation of this same strategy. Thanks to a voucher that is indexed to the rate of inflation, insurance companies would be essentially told what they can charge for the bulk of their insurance. If the health insurers need to charge more, theyll have to wrestle that out of the beneficiary.

2. Tell the providers what they can charge: For an excellent example of this at the state level, check out this article in JAMA that describes Massachusettss just-passed law that aims to control the Bay States $9278 per capita health spending. Large providers (with more than 15,000 patients or $25 million in revenue) are now subject to cost controls that are tied to the states inflation rate.  Enforcement mechanisms will include "performance plan" reviews for violators, public reporting and the threat of civil penalties.

Of course, Medicares fee schedule functionally dictates what providers can charge for their services at the federal level, but up until now, Congress has been unwilling to leverage that. While a softer and gentler approach of "upside risk arrangements" and "global fees" are being developed, the paranoid DMCB suspects that theyll be ultimately calculated to cover a predetermined charge that is supplemented with a small profit margin.

While Democrats and Republicans have been supportive of a limited number of options ultimately lecting their ideology, the DMCB predicts that, over time and with a worsening fisc, both parties will converge on using all of the options described above.  Thats because theyll have no choice.

Heluva way to achieve bipartisanship, but there you go.