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Grinding my teeth

I (Vik) have not written a blog post for TSW in some time. Al is quite capable of regularly exposing the wellness industry’s foibles, an easy task given that there is an endless supply of material, and it multiplies faster than bunnies.

However, I occasionally have an up-close-and-personal interaction that is well worth recounting. My son and I recently visited our dentist for the ritualized annual cleaning and check up. We only go once a year, because as a clinician myself it’s been patently obvious to me for some time that twice yearly cleanings, the benefits of which last only until the next burger, and dental check-ups, which are just a search for billable things to fix, are no more beneficial to the health of my mouth than they are to any other part of my body. What matters is the daily routine of brushing and of avoiding sugar-laden foods. Unless you’ve been sleeping through emerging research, you know by now that I am not the only person to reach this conclusion.

Then I met K, a registered dental hygienist I’ve never previously interacted with at our dentist’s office in the St. Louis suburbs. Within 60 seconds of me reclining in the exam chair, the following exchange took place:

K: “I see that you don’t like having x-rays taken. Is there a reason?”

Me: “There is no evidence that screening x-rays have clinical value.”

K: “Do you have dental insurance?”

Me: “Yes.”

K: “Do you pay for the dental insurance?”

Me: “How is it any of your business how I get the coverage?”

K: “Because if you have dental insurance, the cleanings and x-rays are free, so there is no reason for you to not get them.”

Me (growing increasingly annoyed and now zeroed in like a laser beam): “The dental insurance is part of the compensation package my wife’s employer provides her. Nothing is free. There is a cost to everything.”

K: “Oh, I guess that’s right. Well, anyway, you should have the x-ray to prevent future problems.”

Me: “What your evidence that x-rays prevent problems? X-rays don’t prevent anything. It’s just a way for you to look for things that may or may not ever amount to anything, except that you can paid to deal with them.”

K (now slowly realizing that she has perhaps ventured out of her exceedingly small safe zone): “The American Dental Association….”

Me: “The American Dental Association? That’s not evidence; that’s a trade group. I am not here to get x-rays [I am completely asymptomatic and have a wonderful, clean, healthy mouth], and that’s not open to negotiation.”

K: “Well, if you don’t have x-rays at least once every three years, we will be happy to refer you to another practice [a ‘policy’ never once articulated to me in six years of going to this dental practice], and that’s not open to negotiation. I also need you to sign a waiver that you declined the x-ray against our advice.”

Me: “Have you read any of the new research about dental industry practices, such bite wing x-rays, twice yearly exams, and even flossing. There’s no evidence for any of it. The NY Times, The Wall Street Journal, they’ve all covered it. Have you seen any of it?”

K: “Finding things early [on x-rays] is how you prevent problems.

Me: “Prove to me how that’s the case. You are 100%, utterly and completely wrong, and nothing you’ve told me is evidence.”

At that point she got up in a huff and left the exam room, returning after two or three minutes to, finally, blessedly, actually do her job instead of showcasing her ignorance.

My point in recounting this exchange is this: all the hulabaloo about consumer directed healthcare is garbage if the consumer is faced with quasi-professionals like K, who is blissfully unaware of basic health economics, let alone the changing character of the science and the evidence base for her occupation. According to the Bureau Of Labor Statistics, there are 200,000 dental hygienists, and over 10 years, that figure will grow by nearly 19%. Suppose, conservatively, that each of these hygienists does two cleanings daily over 200 working days per year. That’s 80 million consumer interactions like this one where the paying customer is subjected to intrusion, clinical mythology, deception, and the threat of “dismissal” from the practice for non-compliance with a non-evidence based, but cash-producing pointless clinical service. How many consumers are willing to tell their hygienist or anyone else in a white coat (or, in her case, the custom embroidered frock) that they are wrong?

K, who apparently has either no access to the Internet or no interest in professional improvement, was the very image of an unprofessional professional, with no sense of the notion that she’s not in charge of the relationship. I’m the customer, through the good grace of my wife and her employer, who are the payers.  K did a masterful job of channeling the wellness chimera of Ron Goetzel, Seth Serxner, and Rajiv Kumar, spouting the virtues of overprevention today, overprevention tomorrow, overprevention forever.

For all her ill-informed foaming at the mouth about what’s good for me, here’s what stuck with me, and what I plan to explore further: she, on behalf of the practice, threatened to “fire” me as a client for failure to have an x-ray. There is no legal requirement anywhere in the Missouri Dental Statutes or Rules for me to submit to any radiograph. Nor do the statutes or rules state that a dental office is permitted to dismiss a client for non-compliance with voluntary and discretionary clinical service. What I’d really like to know (enterprising anti-trust lawyers should contact me) is if this is common practice in St. Louis or Missouri more broadly and if yes, how it came to be so.

Can you spell C-O-L-L-U-S-I-O-N? I’ll bet K. can’t.


A little addendum from Al. The other thing these folks do is “screen” you for mouth cancer. I declined the screen. The hygienist said I was making a mistake, that she has found 9 cases in the last three years. Doing the math, if she is average, dental hygienists are finding 600,000 cases a year of mouth cancer. No easy feat considering there are only about 45,000 new cases a year, almost all of which occur in a small segment of the population — tobacco chewers and alcoholics — to which I don’t belong.  I didn’t have to sign anything and she didn’t threaten to “fire” me, but otherwise it was the basically the same experience Vik had.

Just because it’s healthcare, doesn’t mean it’s good for you

Wellness is about pushing employees into the healthcare system, almost always both against their will and their better judgment.  This story is a perfect example of the consequences of how too much healthcare can be hazardous to your health, and why your best defense against overdoctoring is knowledge.

Once you start asking questions, doctors have to start answering them.  While many doctors welcome that, others start fidgeting.  If your doctor is one of the latter, it’s probably time to switch.

I myself get occasional bladder tumors.  Ironically — and once again, showing the unintended consequences of wellness — I got bladder cancer from eating more broccoli, which of course is exactly what wellness programs would have us do.  (And which, in all fairness, is generally a good idea.)  The problem was that the broccoli was grown in a garden that was way too close to railroad ties, which leach creosote into the soil.  Creosote causes bladder tumors.

So every few years, one grows back and has to be scooped out “non-invasively” (that’s easy for the doctor to say).  And every year I go in and get checked, also “non-invasively”.  After my last check, the urologist — a new one, whom I had never seen before — suggested a CT scan of the kidneys and ureters.

I asked her why, and she said, because I had had bladder cancer for 15 years and never had this scan.

I replied: “Well, I founded a company, Quizzify, that educates on overutilization.  CT scans have 500 times the radiation of x-rays, and that particular set of views is likely to spot tumors on my adrenal glands that are completely clinically insignificant, and yet once spotted will be tracked and possibly removed, for no good reason other than that they are there.”

She said: “OK, why don’t we just start with a urinanalysis.”

Quizzify Q in B and W

Quizzify Q&A is your tool to save employees’ time & money

From a hazardous and likely counterproductive $1000 scan to a $10 urinalysis in 30 seconds.  That’s what knowledge is worth.

 

 

Hyperdiagnosis: The Wellness Industry’s Anti-Employee Jihad


Healthmine just released a survey bragging about how many employees were diagnosed through wellness programs. That reminded us of our popular 2013 posting on The Health Care Blog called Hyperdiagnosis.  We are re-posting and updating it below.   


By now we are all familiar with the concept of overdiagnosis, where “we” is defined as “everyone except the wellness industry.”

Wellness vendors haven’t gotten the memo that most employees should simply be left alone.  Instead, they want to screen the stuffing of employees, at considerable cost to the employer and risk to the employee.  The wellness vendors who overscreen employees the most win awards for it, like Health Fitness Corporation did with the Nebraska state employee program.

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:

  1. It is pre-emptive;
  2. It is either negligently inaccurate or purposefully deceptive;
  3. It is powered by pay-or-play forfeitures;
  4. The final hallmark of hyperdiagnosis is braggadocio – wellness companies love to announce how many sick people they find in their screens.

1. Pre-Emptive

Overdiagnosis starts when a patient in need of testing visits a doctor. By contrast, in hyperdiagnosis, the testing comes in need of patients, via annual workplace screening of up to seventy different lab values–most of which, as They Said What? has shown, make no clinical sense.  Testing for large numbers of abnormalities on large numbers of employees guarantees large numbers of “findings,” clinically significant or not.  The more findings, the more money wellness vendors can add on for coaching and the more savings they can claim when they re-test.

2.Inaccurate or Deceptive

Most of these findings turn out to be clinically insignificant or simply wrong, no surprise given that the US Preventive Services Task Force recommends universal annual screening only for blood pressure, because for other screens the potential harms of annual 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 Disease demolishes their highly profitable screening business model.   (We are not cherry-picking titles here—there is no book Here’s an Idea:  Let’s Hunt for Disease.)  And yet most wellness programs require employees to undergo annual screens in order to avoid a financial forfeiture.

Hyperdiagnosis also obsesses with annual preventive doctor visits.  Like screening, though, annual “preventive” visits on balance cause more harm than good.  The wellness industry knows this, because we posted this information on their LinkedIn groups, before we were banned from most of them.  They also presumably have internet access on their own.

3. Pay-or-play forfeitures

The worthlessness, the inconvenience, and the privacy invasion make screens very unpopular.  The wellness industry and their corporate customers “solve” that problem by tying large and increasing sums of money annually — now $694 on average – to participation in these schemes.  Yet participation rates are still low.

4. Braggadocio

While doctors are embarrassed by overdiagnosis, boasting is an essential ingredient of hyperdiagnosis.  We’ve already blogged on how Health Fitness Corporation bragged (and lied, as they later admitted) about the number of cancer cases they found in Nebraska.  They also bragged about the rate of cardiometabolic disease they found — 40% in the screened population — even though they admitted almost no employee did anything about those findings, and only 161 state employees reduced risk factors.  Hence, it was the worst of both worlds:  telling people they are sick without helping them get better.  Nothing like telling someone they’re sick to increase their productivity.

Compass Health is our favorite example of hyperdiagnosis braggadocio.  We realize this screenshot is a bit tough to read, but the hilarity is worth the effort.  We pulled this vignette from On The (even) Lighter Side, They Said What?‘s most popular feature.


The Definition of a “Healthy Employee” Is One Who Has Not Been Diagnosed by Compass Health

Feeling fine today?  Alas, you better get your affairs in order, bid your loved ones adieu, and watch the shows you’ve DVR-ed.  Why? Because, dodo-brain, feeling fine means you have:

compass health title I feel fine syndrome

You are “walking around without a clue that [you have] a debilitating or terminal condition.”  According to Compass Health (which at this point, having been “outed” by us, had the good sense to take this off their website…but not until we captured a screen shot), the major symptom of I Feel Fine Syndrome is:  not having symptoms.

We’ll let them take it from here, to display not only their epidemiological prowess but also, this being the wellness industry, their grammar and spelling prowess as well:

compass health screen shot2

We must confess we learned a lot from Compass.  We had not realized that employers’ concerns about employees feeling fine had their roots in ancient history.  But there it is, right in the opening words:  these concerns date back “millenia” [sic], when employers failed to get their employees tested for “percolating” conditions before throwing them to the lions.

So the bad news is that feeling fine may be hazardous to your health.  The good news is that your ICU bed may not need a DNR notice anytime soon because elsewhere Compass says it “has programs and solutions to help your employees overcome their I Feel Fine Syndrome.”  And it is “very likely” these programs and solutions can “completely cure the problem…forever in our bodies.”

And not a moment too soon, because we’re never felt better in our lives, which means the clock is ticking.  That’s the good news.  The bad news is, if we join Compass’s program it sounds like we need to start contributing more to our 401K’s.


 

Summary

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.

Couple those economics with the advent of genetic testing as part of wellness, big and profitable fines for non-participants, and the EEOC being defanged as a sop to the Business Roundtable, and it’s clear the wellness industry’s highly profitable hyperdiagnostic jihad against the American workforce has barely begun.

By contrast, Quizzify teaches employees that “just because it’s healthcare, doesn’t mean it’s good for you,” and to only get screened according to the USPSTF guidelines.  That’s a message that employees would love to hear, but that wellness vendors can’t afford to tell them.

A Short Painless Primer on the Value of Screening

At the risk of knocking our second-most-widely viewed posting (the first of several analyses of the HERO report) off our front page, this is a brief and amusing lesson on the value of screening

If you like this, you’ll love this–it will also tickle your funny bone.

SSM and HealthFair: what happens when you don’t use Google

saint mary

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
  • EKG
  • 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.

USPSTF AAAAbdominal 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.

Carotid stenosis D

 

 

 

 

Echocardiogram ultrasoundEcho screening no benefit: 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.ECG screening D

 

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.” AHA arterial stiffness

 

 

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.

Quizzify 4

The fun way to save your employees from the medical care industry

 

 

 

SSM – Smoking Gun

Quizzify

The only way to spend less is to spend less

Öèôðîâàÿ ðåïðîäóêöèÿ íàõîäèòñÿ â èíòåðíåò-ìóçåå Gallerix.ruBased in St. Louis, SSM Health was founded in 1872 by the Franciscan Sisters of Mary. It cares for people in a variety of settings including 19 hospitals, physician offices, a pharmacy benefit company, an insurance company, nursing homes, home care, hospice, telehealth and a technology company. It has affiliations with several rural hospitals, while operating facilities in four states: Wisconsin, Illinois, Missouri and Oklahoma.

HealthFair

HealthFair provides consumers easy access to affordable health screenings using mobile health centers, hospital quality equipment and highly trained health professionals. HealthFair eliminates inconvenience and gives control back to the consumer by providing the right combination of tests at the lowest possible cost – all in one convenient 45 minute appointment.

Give the consumer control of their healthcare.

No prescription needed.

Bring state-of-the-art preventive healthcare to your community.

Screening packages are priced affordably.

Short summary of interventions as described by SSM and its vendor, HealthFair:

IMG_20150204_085031091_HDR[1]

Such a deal!

A package of six screenings, available for a limited time 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 is:

  • Echocardiogram ultrasound
  • Stroke/carotid artery ultrasound
  • Abdominal aortic aneurysm ultrasound
  • EKG
  • Peripheral artery disease (PAD) test
  • Hardening of the arteries test (also called the Arterial Stiffness Index or ASI)

The results will be reviewed by a board-certified physician and sent to the screenee within one week. Recipients are encouraged to share the results with their personal physician.

IMG_20150204_085105556_HDR

Wow! More than 1M lives saved. But, who’s counting?

HealthFair has done over 1,000,000 screenings since 1989 and saved “thousands of lives.”

Materials being reviewed

  • Cover letter
  • Flier
  • Flier insert

Questions for SSM

What follow-up and data tracking has SSM done on HealthFair’s claim that since 1989 it has done over 1 million screenings and saved “thousands of lives?”

ANS: Refused to answer

If the results are sent from a bus to a HealthFair doctor to a client that the screening vendor likely never sees again, how is it possible to know that thousands of lives have been saved?

ANS: Refused to answer

What’s the basis for the claim that these screenings are recommended starting at age 45?

ANS: Refused to answer

Why does the flier insert allude to the value of annual exams (“Think an annual check-up is enough?”) when there is no supporting evidence for annual exams in the literature, and in fact, there is a growing consensus against doing them? Even the Obama advisor who helped codify them in the Affordable Care Act now acknowledges reality: in generally healthy adults, they are worthless.

ANS: Refused to answer

How much of the $179 fee goes to SSM? Even though the marketing materials aim to convince consumers this is a great value ($2,300 worth of testing for just $179), and that’s why SSM is doing this, how does it make economic sense for SSM other than in the hopes of generating followup business from all the true and (much more likely, according to the authorities, false positive) diagnoses?

ANS: Refused to answer

How many unnecessary physician visits and subsequent diagnostic tests and therapeutic procedures happen after these screenings? Who is tracking the cost and medical consequences of all that inappropriate care?

ANS: Refused to answer

Quizzify

We actually answer questions.

What do the United States Preventive Services Task Force and the responsible evidence-based medical literature say about each of these screenings?

ANS: Refused to answer

Well, actually, we answer that question for everyone in our blog post related to this Smoking Gun. The post is available here.

Patients overestimate benefits, underestimate harms of treatment. What if they knew the truth? | The Incidental Economist

Trapezoidal_rule_illustrationOne reason most people overestimate the benefits of treatment and underestimate the harms is that the medical care industry is a rigged game. It is about doing things to people, rather than for them, because that’s how everyone (except the patient, very often) makes out financially; if the patient is diligent and lucky he or she achieves an outcome that they value, which could be quite different from the outcomes used to reward providers. The medical care marketing machine is ubiquitous and powerful. Unfortunately, the current debate about overdiagnosis and overtreatment is not cutting very deeply into healthcare excess, for the simple reason that there is too much money to be made by pharma, hospitals, doctors, and health plans.

Quizzify 4

Smarter people make better choices.

The smarter you are about how the healthcare industry makes its money (or takes your and your employer’s money), the better off you will be. The path to successful interaction with the medical care machine lies in skeptical, minimalist interaction.

Despite the existence of metrics to help patients appreciate benefits and harms, a new systematic review suggests that our expectations are not consistent with the facts. Most patients overestimate the benefits of medical treatments, and underestimate the harms; because of that, they use more care.

via Patients overestimate benefits, underestimate harms of treatment. What if they knew the truth? | The Incidental Economist.

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