Monday, October 5, 2015

Health Care Overuse

It takes a very unusual mind to undertake the analysis of the obvious.

Alfred North Whitehead (1861-1947), Dialogues of Alfred North Whitehead

The obvious, which is not so obvious, and the simple, which is not so simple.

The Practical Cogitator, 1959

This day I ran across a Kaiser Health News article “Wellness Programs: Early Alarms for Workers’ Health or a Recipe for Overtesting.”

Its message is obvious. If you do enough testing for health: you will find something wrong, and you will do more tests to confirm what is wrong. One test leads to another. Little tests lead to bigger tests. One abnormal test results in other tests that were not usually planned.

If you do many tests based on metrics, you will either generate false positives or true positives.

Most test results are based on a mean value, plus or minus 2 standard deviations, a normal range that generally encompass 67% of normal results but with inevitable outliers. This means any metric will include normal results but also abnormals outside the normal range. Borderline abnormals may set off alarms that a worker has health problems that may eventuate in diseases later.

Take the problem known as “metabolic syndrome” – a common problem that may be a precursor to heart disease, stroke, or other cardiovascular disease. The metabolic syndrome is defined as: increased waist size, high triglycerides, low HDL cholesterol, high blood pressure, and elevated blood glucose.

These are relatively common findings in any population of workers. Who among us does not know someone with a belly or expanded waist? Elevated triglycerides are common after even modest ingestion of alcohol or a recent carbohydrate rich meal. One third of Americans have high blood pressure, and one of five are either prediabetic or diabetic.

If tests for these conditions are either “free” or mandated by an employer, it is obvious some of these tests will be abnormal, and may lead to other obvious things- a weight reduction regimen, a full lipid panel, blood pressure medications, or a glucose tolerance test. These follow-up tests are necessary to confirm a diagnosis, or to set a preventive program in motion. Workers may regard such testing as an invasion of their privacy. The testing may result in higher costs.

Screening for wellness and for early signs of disease has its problems. It may result in health care overuse syndromes. When HMOs were introduced, routine visits to the doctor and routine testing were encouraged. When ObamaCare health exchanges took hold and the uninsured were subsidized, 10 million people flocked to exchange plans- an insurers found that many of those subsidized were sicker than thought and cost $1000 more than projected, with heavy losses for insurers with losses with insurers being bailed out by government and middle class taxpayers. When new technologies are introduced - CT scans, angioplasties, joint replacements, insulin pumps, lipid lowering statins or other drugs – they are invariably used to excess.

Offer a new technology, and it will be used. Seek an abnormal result, and it shall be found.

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