By Vik and Al
SSM Healthcare is one of the nation’s largest hospital and healthcare systems (more than $3 billion in annual revenues). Based in St. Louis, Vik happens to live in their catchment area, and he was recently treated a promotional mailing promoting a veritable orgy of screenings for cardiovascular disease. SSM has partnered with an organization called HealthFair, which will drive one of its buses to a Walgreens near Vik, where he can clamber on and get screened.
The pitch is that Vik could get a package of six screenings, available for a limited time for the promotional price of $179 (total “value” $2,300), with an additional Know-Your-Numbers lipid panel assessment for just $99. Combine both offers and get an additional $20 off, with a total price of just $258. The six-test package of screenings includes:
- Echocardiogram ultrasound
- Stroke/carotid artery ultrasound
- Abdominal aortic aneurysm ultrasound
- Peripheral artery disease (PAD) test
- Hardening of the arteries test (also called the Arterial Stiffness Index or ASI)
Let’s take a hard look at each of the recommended screenings. For the sake of consistency, we look first to the published recommendations of the United States Preventive Services Task Force (USPSTF) which is the closest thing we have to an independent, credible arbiter of data on preventive services. In cases where the USPSTF has not made a recommendation, we look to the literature.
Abdominal aortic aneurysm ultrasound: Rated “B” only for men aged 65 to 75 with a history of smoking. It’s a C for men in that age with no smoking history, “I” or inconclusive for women 65 to 75 who’ve smoked, and a D (more harmful than helpful) for women in this age range with no smoking history. Why does the promotional material contain no stratification by age, gender, or smoking status?
Stroke/carotid artery ultrasound: rated a D for all adults who are asymptomatic. Someone with symptoms doesn’t need a screening; they need a workup and therapy.
Echocardiogram ultrasound: the USPSTF doesn’t even have a recommendation on this, so we look to the literature. A large, long-term study from Norway, published in JAMA Internal Medicine in 2013, concluded that echo has no prognostic value. This jibes with the recommendations of the American Society of Echocardiography, articulated at Choosing Wisely, that echo is overused even in people who are symptomatic and should be avoided in people who have no reason to get one.
Electrocardiography or EKG: USPSTF rates this a D for adults with no symptoms and of inconclusive value even for people in moderate or high risk categories.
Peripheral artery disease (PAD) test: The USPSTF rates this screen as I or inconclusive. They do say, however, that the incidence of PAD in the general population is unknown. While this testing has value in people who are symptomatic, they were not coy about its value in people with no symptoms: “The USPSTF found no evidence that screening for and treatment of PAD in asymptomatic patients leads to clinically important benefits.”
Hardening of the arteries test (also called the Arterial Stiffness Index or ASI): The USPSTF has no recommendation on this. But, the American Heart Association, which typically doesn’t softsell cardiac goods and services, completely disses this test: “On the other hand, genotyping, other lipoprotein and apolipoprotein measurements, natriuretic peptides, hs-CRP for high- or low-risk adults, brachial/peripheral flow-mediated dilation, measurement of arterial stiffness, contrast computed tomography angiography and plaque imaging by magnetic resonance imaging are not recommended (Class III). The lack of support for these tests may change as more evidence is acquired. However, future recommendations will have to fully consider cost-effectiveness before reclassifying them.”
In sum then, we would like to know how and why SSM and HealthFair are selling their St. Louis audience a package of six screenings that, with only one exception, are recommended NOT to be done by the evidence-based medical community. Read that carefully. “Recommended NOT to be done” is different from — way worse than “Not recommended to be done.”
And yet this hospital seems to be unfamiliar with medical guidelines.
A cynic might say “No, they have an internet connection that reaches USPSTF and understand medical guidelines. They choose to ignore them, in order to create followup revenue for the (mostly false) positives that these tests will inevitably reveal. And the reason they are practically giving them away is that they not covered by insurance because the Affordable Care Act requires health plans to cover only screens that are A or B rated by the USPSTF. However, all the followups will be well-reimbursed.”
SSM is not alone in the screenings charade; in fact, in St. Louis, Vik is regularly treated to an onslaught of screening propaganda from Siteman Cancer Center at Washington University in St. Louis: currently making the claim that “where you get your mammogram matters.” Other than singing the virtues of their own radiologists and perpetuating the myth that early diagnosis is the same as a life saved, we see no evidence on the Siteman website that their strategy actually reduces mortality. Last fall, Siteman was running an ad on St. Louis radio station enticing women to come get a mammogram and register for a cruise vacation.
Our suggestion to generally healthy, symptom-free adults living near any one of these organizations? Use your $179 to buy a couple of really good pairs of running shoes instead. Then, when some medical care vendor starts yammering to you about the predictive and life-saving values of screenings, you can literally run for your life.
Don’t depart without reading our Smoking Gun entry on SSM at this link.