A good deal of health reform attention has focused on the value of prevention and wellness programs. Unfortunately, one of the prime examples used as “prevention” by the Congressional Budget Office and others is screening. Screening might be more appropriately classified as early disease/at-risk identification, as opposed to prevention of disease or maintenance of health. Because screening implies looking at a relatively large population segment, it can be expensive and it is often unclear how much additional health cost it creates and how much it saves. A New England Journal of Medicine article examining coronary calcium screening is a good illustration of the dilemma for many screening services. (NEJM Article)
Calcium in coronary arteries is, with very rare exception, evidence of arteriosclerosis. Calcification does not mean there is an obstruction or an imminent coronary event which threatens health. Electron beam computed tomography and multidetector computed tomography are used to find and score calcification. These are not inexpensive tests and they give a patient a fairly significant dose of radiation. The results of these tests may lead to more tests–even procedures–which add to total health care costs. While the diagnostic information gleaned from the tests may be useful, it has not to date been clearly correlated with better overall clinical outcomes–fewer heart attacks. The specialty organizations have indicated that the test may be appropriate in some people but have not recommended its use.
It is reasonable to suspect that notwithstanding the ambiguous utility and benefit of these tests, or perhaps because of that, many patients may be requesting them and many physicians, requested or not, may be ordering them. This is the essence of the effort to control costs–to what extent will payers be able to refuse to pay for services unless and until there is clear evidence that the tests will lead to better health outcomes for the patients receiving them. And to what extent will physicians be willing to, or feel comfortable, not ordering tests when there is not such clear evidence, particularly if there is a liability exposure for not performing the test.