The Health Shopper

Several insurance companies are placing restrictions on CT scans for policyholders and in many instances are requiring plan members to receive pre-authorizations before undergoing the scans. Insurers are following the lead of Medicare, which announced and then retracted restrictions on CT scans, due to limited clinical evidence supporting their use. At the time of Medicare's reversal, the New York Times noted that "The proposal to curtail payments met with fierce resistance from doctors who perform these scans and companies that make the equipment" who "strongly defended the scans." Medicare alone spent as much as $50 million on the scans in 2006, and in the past six years, their use has been increasing 13 percent annually.

Evidence in favor of their widespread use remains weak, however. A few months ago, Consumer Reports listed CT Scans as one of the ten most overused medical treatments in the United States. A month later, a group of researchers writing in the New England Journal of Medicine found that approximately one third of CT scans were unnecessary, exposing "perhaps 20 million adults and, crucially, more than 1 million children per year in the United States" to a radiation dose roughly equal to 85 to 200 chest x-rays.

The good news is that requiring pre-authorizations seems to work. According to a study by the Robert Wood Johnson Foundation's Center for Health System Change, a health plan that required pre-authorization of the scans successfully reduced the growth rate on scans while denying only 1.5 percent of scan requests. As one insurer said, "We're not saying ‘No' that much, but because people have to now justify what difference the test is going to make, they aren't requesting it as much."

The New York Times has a long feature on DNA testing about some of the barriers to widespread DNA testing. The story notes that people are hesitant to undergo genetic tests that might provide useful information about their medical risk for fear that insurers will use the test results to deny coverage or increase rates, leading directly and indirectly to worse care. In one case cited by the Times, a 16 year old girl knew of a family history of blood clotting abnormalities-detectable through DNA testing-who refused to take the test because of privacy concerns. After starting to take birth control medication, which also increases blood clotting risk, she "developed a clot that stretched from her knee to her abdomen."

Despite the availability of accurate tests, some individuals are still relying on family history to make decisions about their medical care. For example, one woman cited by the Times decided to have her ovaries removed because of a family history of ovarian cancer-something detectable through genetic testing-but refused to undergo the test, for fear that it would also show her to be at high-risk for developing breast cancer.  

The story echoes a Vimo Report on personalized medicine that we released last month, which discussed how the lack of privacy protections has slowed the growth of genetic testing. In the long run, as we noted, limits on genetic testing now will delay treatment breakthroughs in the coming years.

A recent review article in the New England Journal of Medicine has found that the use of CT scans to diagnose patients has increased dramatically over the past two decades leading to potentially dangerous overexposure to radiation. When used appropriately, CT scans can be extremely useful diagnostic tools. Unfortunately, approximately one third of scans seem to be unnecessary, despite the "direct evidence from epidemiologic studies that the organ doses corresponding to a common CT scan…result in an increased risk of cancer."

David Brenner, lead author on the study, suggests that doctors have a limited understanding of the risk involved with radiation-or the amount of radiation exposure with CT scans-and as such, are prescribing the scans for patients regardless of whether the scans have been shown to provide an advantage over other diagnostic techniques.

The Wall Street Journal today reports that several new companies including Navigenics and 23andme have begun or are planning to begin offering direct-to-consumer genetic screenings for a wide variety of diseases. Tests for individual genes and rare diseases such as Tay Sachs or Huntington's Disease have been in use for a few years now. These new efforts will attempt to expand on this individual screening to provide comprehensive screenings for approximately 20 common afflictions including obesity, diabetes, and heart attack. Navigenics will also offer educational information on lifestyle changes people can make to lower their disease risk.

At more than $2,000 a test these screenings aren't cheap. Screenings also face several other hurdles, including privacy concerns, fears that finding out genetic risk will disqualify a person from jobs and insurance, and the feeling that a lot of the links between disease and genetics are still too tenuous to have predictive value.

This isn't the first effort to bring genetic testing to the masses. In 1998, geneticist Craig Venter claimed that in five years, Americans would store their genetic information on a card no bigger than a credit card. On the other hand, science has progressed dramatically in the intervening decade and new screening plans are more modest. And as the Wall Street Journal notes, these companies are seeking to tap into the consumer market at a time when individuals are actively seeking a greater role in their own preventive care.  

If you are paying for your own health care, either through an HSA or out of your own pocket, you'd be wise to check out the November issue of Consumer Reports, which identifies the Top 10 most overused medical tests and treatments.

Most doctors and hospitals are paid on a "piecework basis," which means the more tests and surgeries they perform, the more revenue they generate. This might be fine with you — if all your bills are being paid by your insurance company. But more and more Americans are becoming responsible for their own medical bills.

The Top 10 Most Overused Medical Tests and Treatments, according to Consumer Reports, are:

1. Back surgeries. "Don't rush to surgery for a simple slipped disc. In 90 percent of cases, the pain goes away on its own within six weeks."

2. Heartburn surgeries. A nearly $15,000 surgery offers as much relief as a proton-pump-inhibitor which only costs $1 a day.

3. Prostate Treatments. "Prostate cancer is often overtreated by surgery that costs $17,000, or by radiation therapy for $20,700 or more, plus physician's fees, without adequate discussion of the alternatives …"

4. Implanted Defibrillators. "[O]ne-third of people who get them might not really need them, according to research reported in 2007."

5. Coronary Stents. For patients with stable coronary artery disease, this procedure along with heart drugs works no better at preventing future heart attacks than drugs alone.

6. Cesarean Sections. Used for a record high of 30.2% of births in 2005.

7. Whole-Body Screens. "There are no proven benefits for healthy people, the Food and Drug Administration has concluded."

8. High-Tech Angiography. It can be a waste because "standard angiography is sometimes still needed to confirm blockages that might require aggressive treatment."

9. High-Tech Mammography. "[A] 2007 study found that this technique failed to improve the cancer-detection rate significantly, yet resulted in more needless biopsies."

10. Virtual Colonoscopy. The procedure isn't cost-effective because suspicious findings require the real thing.

An interesting news item from Information Week:

The Independent Health Record Trust Act, which was introduced into Congress in mid-July by Rep. Dennis Moore (D-Kan.) and on last count this week has bi-partisan support from 49 House members, aims to create independent health record trusts, or IHRTs, that would manage the electronic medical records of patients upon voluntary participation by consumers signing up for these electronic accounts.

Health records that follow you even after you leave an HMO or PPO would make a trip to any doctor quick and easy because any physician would be able to look at your history. If you were totally unconscious after a car crash, doctors could still find out your prior medical history before treating you — whether or not you had ever been to a doctor in the same network. But many health consumers will likely want the option not to participate in the program if they feel the system infringes on their privacy in any way. Also, we'll see if consumers are comfortable with the idea of doctors being financially rewarded for entering patient data into the system:

On top of that, doctors could also be financially rewarded for submitting authorized patient data to the trust through "sharing" the trust's revenue. The "revenue sharing" with doctors would be non-taxable income for the physicians, another benefit.

Giving health consumers online access to their claim and health histories is one more step in consumer empowerment. Blue Cross patients across the nation are now getting a tool to help them manage their healthcare online.

A new program called '360 Health' is being launched across the nation. Anthem Blue Cross and Blue Shield in Maine, Blue Cross of California, Anthem Blue Cross and Blue Shield in Connecticut, Blue Cross and Blue Shield of Georgia, and Anthem Blue Cross and Blue Shield in New Hampshire have all adopted the new health program that leverages technology to enable consumers to better manage their healthcare.

360 Health integrates health management programs and tools into a centralized, consumer-friendly online resource that assists members in navigating the health care system, using their health benefits and providing information to access comprehensive and appropriate care. A key future component of 360 Health is MyHealth Record, an online personal health record owned and managed by members. MyHealth Record is automatically populated by member-provided information plus claims data received by WellPoint, Anthem's parent company. Claims can be accessed from any computer with an Internet connection, allowing members to track and share their health histories.

This news broke on Computerworld:

"A trade association representing almost 1,300 insurance companies with 200 million customers announced last week that all of its members have agreed to support a common set of standards for creating and managing electronic personal health records.

"America’s Health Insurance Plans (AHIP) compiled the standards with Blue Cross and Blue Shield Association.

"Scott Serota, president and CEO of the Chicago-based Blue Cross network, said that all 39 Blue Cross and Blue Shield plans in the U.S. are aiming to offer standards-based personal health records (PHR) to their 98 million clients by the end of 2008.

"PHRs allow individuals to manage and view their own health information."

Talk about transparency! We'll soon be able to view our own medical records online, the same way we can review bank account information. But it also brings up another question with regard to privacy: Will insurers use the information to deny coverage? Not suprirsingly, they're saying they won't. Still, privacy will no doubt be a concern some people have with the program. Aetna will begin offering it to 1 million of its 15 million clients in February of 2007.