What Breast Cancer Screenings Reveal about Cost Control

Sometimes changes to cancer screening recommendations are actually just changes to cancer screening recommendations. But judging by the backlash against new breast cancer screening guidelines released this week by the U.S. Preventive Services Task Force, sometimes they represent deeper problems and frustrations with the healthcare system.

After reviewing literature on the effectiveness of mammograms and other screening methods, the USPSTF recommended against routine mammography for women 40 to 49 years old and suggested women 50-74 get a mammogram every two years. Previous guidelines recommended annual mammograms for women over 40. The study found insufficient evidence to assess benefits for women over 75, and the task force recommended against teaching breast self-examination.

Some see this as an initial foray into the realm of comparative effectiveness research, which the Obama administration hopes will improve care and keep costs down. If that's what it is, the road ahead will be bumpy, judging by the reactions.

Both physicians and patients came out firing at new guidelines. Some patients saw it as a denial of services and worried that their cancer will go undetected. Officials with the Access to Medical Imaging Coalition and the American College of Radiology flamed these fears with borderline fear-mongering language when they warned that "countless American women may die needlessly from breast cancer each year."

Not everyone was critical, however. The National Breast Cancer Coalition applauded the decision and has for more than a decade argued that there has been too much emphasis on breast cancer screening. The USPSTF report claims that screening every other year is just as effective as screening annually, and it reduces the false positives or overdiagnosis rates, which can be as high as 10%.

I don't have the clinical expertise to evaluate the soundness of the guidelines, but I think this episode illustrates the difficulty in implementing comparative effectiveness guidelines and the real cost conundrum facing U.S. healthcare.

Consider how patients, physicians, and the government approach the problem:

Patients
What they say: Cancer terrifies most people. When a physician tells a patient that a specific test or procedure isn't needed 99 times out of 100, the patient's mind is usually focused on the one time that it is necessary. That 1% may be statistically insignificant to a researcher or clinician, but to the rare patient whose cancer goes undiagnosed it represents the difference between life and death. It's hard to argue numbers when someone is facing the potential end of their entire existence. The big question going forward is whether patient demand for services will be affected at all by evidence-based guidelines.

What's left unsaid: Patients can take a chance on unnecessary screenings in part because they don't directly pay for them. Insured patients do shell out thousands of dollars in premiums every year, and many would argue that they're paying for services like mammograms with those dollars. But the disconnect between the direct cost of the test and the amount paid for insurance means patients can make decisions about receiving more tests while the direct cost is shifted elsewhere.

Physicians
What they say: Physicians want better evidence about which treatments and screenings work. However, they are genuinely concerned about patient care and don't want to jeopardize patient safety, so if evidence-based guidelines aren't sound, physicians aren't going to follow them.

But there are also concerns about liability if a serious illness or injury sneaks by undiagnosed, and many physicians admit that they order imaging tests defensively. Some doctors are also worried that the toothless guidelines will someday lead to financial restrictions on the care they can provide.

What's left unsaid: Let's not pretend it's not about money, at least in part. If women in certain age groups are getting mammograms half as often, it's easy enough to do the math for how that will affect the physicians who perform a high-volume of the procedure. It's tempting to blame the fee-for-service system or criticize the evidence. But there are times when a group of physicians looks at the evidence and looks at the revenue loss, and decides against what's best for the patient.

Government
What they say: Comparative effectiveness research will ideally help physicians get better value—defined by the best quality at the least cost—out of their healthcare decisions. Even without "rationing care," CER can improve healthcare by giving doctors better information when making decisions. Instead of one-sided reports from drug or device companies, they would have a broad analysis of how a treatment performs when compared to alternatives.

What's left unsaid: The task force says cost was not considered in its research, and Health and Human Services Secretary Kathleen Sebelius said the recommendation is in no way government policy. But it's difficult to believe that will always be the case. Those false positives waste money, after all.

Statistics can be manipulated, and studies can be flawed. For instance, there don't seem to be any radiologists or oncologists currently on the USPSTF. Could that have affected their interpretation of the findings? Furthermore, how will the government respond if it issues guidelines based on scientific evidence and providers don't follow them? At some point, the debate over rationing and mandating care protocols may come back up.

This is just the beginning. There are similar questions about prostate cancer screenings, colonoscopies, and other procedures. Comparative effectiveness research is a solid idea, but it is going to be tough to implement. And even if it's effective, it will only get at a fraction of the cost problem.

Expanding access? It's tough politics, but easy enough. Improving quality is a challenge but many providers are making giant strides. Controlling costs, however, will prove to be the biggest challenge in remaking healthcare, and everyone involved in the system shares a little of the blame.