[Reblog] Hyperdiagnosis: The Wellness Industry Doubles Down on Overdiagnosis

Thinking that ideally everyone would  have a health care provider that knows one’s  medical history well.
S/he can then best work with you on deciding which screenings are best for you.

 

From the 5 November 2013 item at The Health Care Blog By AL LEWIS AND VIK KHANNA

By now we are all familiar with the concept ofoverdiagnosis, where “we” is defined as “the readers of THCB and a few other people whose healthcare literacy is high enough to know when not to seek testing and/or when not to automatically believe the test results.”

The rest of the country hasn’t gotten the memo that, quite counter-intuitively, many suspected clinical problems should simply be left alone.  Many insignificant conditions get overdiagnosed and subsequentlyovertreated, at considerable cost to the health plans and risk to the patient.

For more information on that we  refer you to the bookOverdiagnosed.   The thesis of that book is that insured Americans are far more likely to be harmed by too much care than too little.

Rather than use its resources and influence with human resources departments to mitigate overdiagnosis, most workplace wellness companies have opted for the reverse, taking overdiagnosis to a level which, were they physicians billing the government for this work, could cost them their licenses and possibly their freedom.   Instead, they winawards for it.

We call this new plateau of clinical unreality “hyperdiagnosis,” and it is the wellness industry’s bread-and-butter.  It differs from overdiagnosis four ways:  It is pre-emptive.  It is either negligently inaccurate or purposefully deceptive.  It is powered by pay-or-play forfeitures.  The final hallmark of hyperdiagnosis is braggadocio – wellness companies love to announce how many sick people they find in their screens.

1. Pre-Emptive

Most cases of overdiagnosis start at the doctor’s office, when a patient arrives to join the physician in a generally good faith search for a solution to a manifest problem.  The patient comes in need of testing.   By contrast, in hyperdiagnosis, there is neither a qualified medical professional providing adult supervision nor good faith.  The testing comes in need of patients, via annual workplace screening of up to seventy different lab values.  Testing for large numbers of abnormalities on large numbers of people guarantees large numbers of “findings,” clinically significant or not.  It is a shell game that the wellness vendor cannot lose.

2.Inaccurate or Deceptive

Most of these findings turn out to be clinically insignificant, no surprise given that the US Preventive Services Task Force recommends annual screening only for blood pressure, because otherwise the potential harms of screening outweigh the benefits.  The wellness industry knows this, and they also know that the book Seeking Sickness:  Medical Screening and the Misguided Hunt for Diseasedemolishes their highly profitable screening business model.   (We are not cherry-picking titles here—there is no book Hey, I Have a Good Idea:  Let’s Hunt for Disease.)  And yet most wellness programs require annual screens to avoid a financial forfeiture.   This includes the four programs covered on THCB this year — CVS, Nebraska, British Petroleum, and Penn State.

Those four programs and most others also obsess with annual preventive doctor visits.  Like screening, though, annual “preventive” visits on balance cause more harm than good, according to academic and lay reports.  The wellness industry knows this as well.  We have posted it on their LinkedIn groups, and presumably they have also access to Google.  They addressed the data by banning us from their groups.

3. Pay-or-play forfeitures

Because of the lack of value, the inconvenience, and privacy concerns, most employees would not submit to a workplace screen if left to their own devices.  The wellness industry and their corporate customers “solve” that problem by tying large sums of money annually — $600 for hourly workers at CVS, $1200 at Penn State and $521 on average – to participation in these schemes.  Yet participation rates are still low.  At Penn State, for example, less than half of all employees got screened despite the large penalty.

4. Braggadocio

Few doctors would publicly brag about how many cases of hidden disease they found, especially if they couldn’t convince the patient to do anything about their condition.  But boasting is essential to hyperdiagnosis.  We’ve already blogged on how Nebraska’s program sponsors bragged (and lied, as they later admitted) about the number of cancer cases they found.  They also bragged about the rate of cardiometabolic disease they found — 40% in the screened population — even though they admitted almost no one did anything about those findings.  Hence, it’s the worst of both worlds:  telling people they are sick without helping them get better.

We’d like to think that all our exposés have made a dent in the wellness industry’s business model, but the forces arrayed in the other direction have so far overwhelmed us.   The price of screening has plummeted almost to the $1-per-lab-value level for comprehensive screens, and as with anything, the lower the price, the greater the amount sold.

More ominously, starting in January employers are allowed to tie 30% of premiums to health-contingent employee wellness programs.   And they will, thanks to the canard — also debunked on THCB — that the CDC says 75% of health spending is somehow preventable through wellness.   This statistic is gospel among benefits consultants, vendors and even pharmaceutical companies like Astra-Zeneca and Johnson and Johnson, which should know better.  So as far as the wellness industry is concerned, a 30%-of-premium penalty only scratches the surface, meaning that their hyperdiagnostic jihad against the American workforce has barely begun.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

Related Posts

• My Personal Affordable Care Act–A Manifesto
• The Summer of Wellness’s Discontent
• The Other Penn State Scandal
• Is Obesity a Disease? I Vote No

Related articles

• Overdiagnosis (whatreallymattersinhealthcare.wordpress.com)
• Patients report doctors not telling them of overdiagnosis risk in screenings (medicalxpress.com)
• Millions Wrongly Treated for ‘Cancer,’ National Cancer Institute Panel Confirms (fromthetrenchesworldreport.com)
• Doctors Rarely Discuss Risks of Cancer Screening (nlm.nih.gov)
• Too Much Medicine Is Bad For Our Health – by Allen Frances MD (therefusers.com)
• Mammogram Alternatives Can Also Be Dangerous (And Often Are) (rinf.com)
• Patients report doctors not telling them of overdiagnosis risk in screenings (eurekalert.org)
• Warning over rise in ADHD misdiagnosis (irishtimes.com)
• Doctors rarely discuss cancer screening risks (sumantasaha.com)

Overdiagnosis: An epidemic or minor concern?

From the 24th January 2013 article at Medical News Today

An editorial by two oncologists in the New Year’s issue of Annals of Internal Medicine discusses overdiagnosis, a controversial health problem that some have called “a modern epidemic” but others, including the editorialists, feel is a minor concern. Although many chronic conditions are overdiagnosed, cancer is the most thoroughly studied, as well as the most emotionally charged.

I am a generally healthy man with no family history of significant health problems. Yet increasing numbers of men like me who are approaching middle age may be shadowed by a sniper on a rooftop, each armed with a highly accurate loaded rifle pointed directly at our heads. By age 70, nearly half of all men will be shadowed by a sniper, though in only 3 percent of us will he actually take the fatal shot. A 1 in 30 chance of being assassinated without warning still seems too high, and therefore health authorities concerned about the problem of snipers on rooftops recommend that all men after age 50 (or perhaps 40) be offered routine surveillance to determine if there’s a sniper up there. If there is, perhaps he can be safely disarmed.

The  trouble is, the disarmament team is successful at best, 21 percent of the time(reducing a man’s chance of being shot from 3 percent to a barely more reassuring 2.4 percent), and at worst, hardly ever. In addition, attempts to subdue snipers by force often lead to unwanted consequences: stray shots fired in the scuffle that causenon-lethal but persistent injuries to the bladder and reproductive system. In about 1 in 300 men, the attempt to disarm the sniper goes terribly wrong, causing the gunshot to miss the head but deliver an equally fatal round through the heart….

…

Back to the Annals editorial about overdiagnosis in breast cancer. The authors write:

We believe that the term “overdiagnosis” in the context of breast cancer places this problem in an inappropriate light, suggesting that these patients do not have cancer. The question is not whether we should find early, more easily treatable cases of breast cancer but rather how to treat early-stage cancer found on mammography. … For the individual patient, the question is not whether to have a mammogram that might “overdiagnose” breast cancer but how to treat the early-diagnosed non-invasive or invasive breast cancer once we have found it.

…

Finally, I apologize to any of you who were offended by my explicit comparison of overdiagnosis to gun violence, given the recent tragedy that has drawn belated attention to the latter as a public health problem.

 

 

Related articles

• Cancer Expert Remains To Be Convinced By Breast Screening Review (medicalnewstoday.com)
• Cancer Survivor or Victim of Overdiagnosis? (nytimes.com)
• The medical fiasco (dawn.com)

 

Related posts at this blog

• The medicalization of modern life
• More information does not equal better care
• Critics detect hype in “Bra Detects Cancer” news
• Nine (9) part series on over diagnosis
• Is preventative medicine really over treatment?

 

More information does not equal better care

 Chalmette, LA, December 16, 2005 – A patient describes his symptoms with a nurse at the Primary Care Clinic in St. Bernard Parish. The facility located in a triple-wide office trailer offers free medical care to area residents, staffed by personnel from the U.S. Public Health Agency and FEMA Disaster Medical Assistance Team (DMAT). Robert Kaufmann/FEMA

A wise, sobering post on the limits of medical/health related information.

Technology is increasingly used to collect and store personal health and medical data. While the amount of personal stored data is rising, this does not necessarily translate into better care. For example, the information stored in electronic medical records is only as good as the data entered.  Medical devices (as imaging and gene testing instruments) generate data that may or may not be useful depending on why they were ordered and how they results are interpreted.

The use of the data is also troublesome. As this post states, medical test results are often misused by the diagnostics industry in over testing.  This leads to unneeded treatments which divert money and resources.  Health care providers, especially those in primary care have less time to listen to and counsel patients.

The money spent on unnecessary treatments is a burden not only on individuals, but also health care facilities and government agencies. Health care facilities become caught in a spiral of justifying diagnostic equipment through marketing and at some point they will find it nearly impossible to recoup their investments. Medicare and Medicaid funds are not used wisely to diagnose and treat, resulting in ever more increased costs to the system.

As this post points out, health care providers would be wise to take a deep look at their role and be realistic about their expectations.
The same can be said about those who consult with health care providers.

From the 1 November 2012 article at KevinMD.com

I have found that this concept is hard for non-healthcare people to really grasp – that a less aggressive testing approach knowingly misses disease, but makes no difference in the overall prospects of the patient. It is crucial that the U.S. culture fights the prevailing scare tactics of the diagnostics industry, or we’ll never lower the rate of over testing. Any administrative tricks to lower testing rates will be subverted by both physicians and patients who assume more tests equal better care unless the underlying culture and conventional beliefs are changed.

The change required is deeper than administrative rules. It has to come from a more humble attitude on the part of doctors, patients, employers, and insurers that just because a patient could be labeled as having a disease, there is nothing to be gained by doing anything about it. More information does not equal better care.

Our American culture proclaims, “Just Do It.” To reclaim resources from the healthcare industry and return them to the general economy, we must proclaim, “Don’t just do something for the sake of doing something, stand there.”

 

Related Resources

• US Agency for Healthcare Research and Quality (AHRQ)- Consumers and Patients
  • Choosing Quality Care
  • Comparing Medical Treatments
• Evaluating Health Information (Health Resources for All Edited by Janice Flahiff)

Related articles

• Why Health Care is a Civil Right (jflahiff.wordpress.com)
• Misinformation in electronic medical records has consequences (kevinmd.com)
• Shared Decision Making Leads To A Better Patient Experience And Higher Levels Of Patient Satisfaction (introcomm)
• Supplies and Devices Are Biggest Cause of Hospital Cost Increase(jflahiff.wordpress.com)
• 9-part series on over-diagnosis (HealthNewsReview.org)

More information does not equal better care

From the 1 November 2012 article at Medical News Today

…I have found that this concept is hard for non-healthcare people to really grasp – that a less aggressive testing approach knowingly misses disease, but makes no difference in the overall prospects of the patient. It is crucial that the U.S. culture fights the prevailing scare tactics of the diagnostics industry, or we’ll never lower the rate of overtesting. Any administrative tricks to lower testing rates will be subverted by both physicians and patients who assume more tests equal better care unless the underlying culture and conventional beliefs are changed.

The change required is deeper than administrative rules. It has to come from a more humble attitude on the part of doctors, patients, employers, and insurers that just because a patient could be labeled as having a disease, there is nothing to be gained by doing anything about it. More information does not equal better care.

Our American culture proclaims, “Just Do It.” To reclaim resources from the healthcare industry and return them to the general economy, we must proclaim, “Don’t just do something for the sake of doing something, stand there.”..

 

Related articles

•  9-part series on over-diagnosis (short reads from a health care journalist) (jflahiff.wordpress.com)
• Most patients don’t need extra tests for diagnosis (jflahiff.wordpress.com)
• Supplies and Devices Are Biggest Cause of Hospital Cost Increase (jflahiff.wordpress.com)

 

 

9-part series on over-diagnosis (short reads from a health care journalist)

Over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them. 

www.shutterstock.com

 

From the 3 October 2012 blog article by Gary Schwitzer at HealthNewsReview.org

Ray Moynihan, a terrific health care journalist who is now pursuing his PhD on overdiagnosis and working as a Senior Research Fellow at Bond University in Australia, kicks off the first of a nine-part series, “Over-diagnosis Epidemic” on TheConversation.edu.au website.

The first part is an introduction, “Preventing over-diagnosis:  how to stop harming the healthy.”

“To put it simply, over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them. It happens because some screening programs can detect “cancers” that will never kill, because sophisticated diagnostic technologies pick up “abnormalities” that will remain benign, and because we are routinely widening the definitions of disease to include people with milder symptoms, and those at very low risk.”

Other colleagues author the subsequent parts in the series:

Part two: Over-diagnosis and breast cancer screening: a case study

“…But what we found was that the greatest relative reduction in breast cancer mortality (44%) occurred in the youngest age group. These women (aged 40 to 49 years) are not invited for screening. In contrast, women aged 60 to 69 years, who areinvited to screen, had the smallest relative reduction in mortality (19%).

Given that three times as many women aged 60 to 69 (about 60%) participated in Breastscreen (compared to 20% of women aged 40 to 49 years), our finding is not consistent with screening having a major impact on the reduction in breast cancer mortality since 1991.”…

Part three: The perils of pre-diseases: forgetfulness, mild cognitive impairment and pre-dementia

“…Most studies show that only one in ten cases of mild cognitive impairment progress to dementia each year, and many improve. One study that followed outcomes for ten years concluded – “The majority of subjects with MCI do not progress to dementia at the long term.”…

Part four: How genetic testing is swelling the ranks of the ‘worried well’

“..A major concern with such tests is that they’re the beginning of a path toward over-diagnosis, where the potential to develop a disease or being at risk for the disease is strong enough to constitute a label of sickness.

Over-diagnosing includes, but is not limited to, widening disease definitions, early detections of abnormalities that may or may not cause symptoms or death and the use of increasingly sensitive technologies that detect “abnormalities,” the causes and consequences of which are unknown at this time…”

Part five: PSA screening and prostate cancer over-diagnosis

Part six: Over-diagnosis: the view from inside primary care

“..The most common reason general practitioners are sued is because of missed diagnoses. Missed diagnoses also invoke a strong sense of professional failure. So how can general practitioners manage in this sea of uncertainty?

One way is to perform more tests. This is also popular with patients, who perceive that tests ensure nothing serious is missed. What is not well understood by patients (and sometimes also by clinicians) is the potential harm from testing.

The most obvious harm is the cost and resources required; we would quickly overwhelm the health system if we performed an MRI on every patient with back pain. A strong system of primary care results in a health-care system that’s both more efficient and less costly because primary-care physicians are skilled at filtering those with severe disease needing further tests, from those with self-limiting illnesses…

…

The greatest harm from the increased use of testing, however, is not costs, resources or false positives. Rather, it’s the problem of over-diagnosis.

Clinicians and patients both believe that finding a disease earlier in its process means it will be more successfully treated. But there’s increasing evidence that finding disease early or at a milder stage has paradoxical harmful effects, even reducing survival and quality of life.

Wider availability of more sophisticated tests results in “incidentalomas”, incidental findings that would not have otherwise been diagnosed. The detection of thyroid cancers, for instance, has more than doubled in the past 30 years. But most of these diagnoses are incidental findings from imaging…”

Part seven: Moving the diagnostic goalposts: medicalising ADHD

Part eight: The ethics of over-diagnosis: risk and responsibility in medicine

Part nine: Ending over-diagnosis: how to help without harming

 

 

Related articles

• #Preventing #over-diagnosis #good #healthy (leggotunglei808.wordpress.com)
• What good is a diagnosis? (wisecounsel.wordpress.com)
• Biopsies may misdiagnose eosinophilic esophagitis (yvonnebergeron.wordpress.com)