study of the week

Study of the Week- Screening for Ovarian Cancer

It’s very rare that a month goes by without someone bringing me a copy of this email.  It’s been circulating on the internet since 1998.  It is a true story, with some caveats, about a woman named Carolyn Benivegna who was diagnosed with ovarian cancer.  In the email, she implores women to DEMAND a CA-125 test on an annual basis and to “not take no for an answer.”  According to her email, if only this simple, accurate test was done, her diagnosis would have been made earlier, thereby improving her odds of survival.

So, what is a CA-125 test?  It is simple to do.  It’s just a blood test.  It measures CA-125, a protein that is found in higher concentration in tumor cells.  In general, it is higher in ovarian cancer cells than other cells. However, many conditions can cause a CA-125 to be elevated, including endometriosis and fibroids.  This means the test is very non-specific, meaning that there will be a lot of false positives (people have a high CA-125 but don’t actually have ovarian cancer).  Many people might read this and say, so what?  Who cares if there is a false positive?  I’d rather know if I have cancer, and I don’t care if it involves some extra testing!

So, here’s why that is not the right way to look at this.  This is a recent study published in JAMA.  It discusses some of the results of the PLCO Trial.  The PLCO trial is a 10 year study slated to be completed in 2015.  It evaluates screening methods for prostate, lung, colorectal and ovarian cancer.  The results of the ovarian cancer screening arm are very interesting.

The study looked at 78,216 women.  Half of them were randomized to receive ovarian cancer screening in the form of an annual CA-125 test and transvaginal ultrasound (to look at the ovaries).  The other half had “usual care,” basically meaning no screening.  Here are the results:
     212 women in the screening group were diagnosed with ovarian cancer; 118 of them died
     176 women in the usual care group were diagnosed with ovarian cancer; 100 of them died
     5838 women in total died of other causes
     There was NO decrease in mortality in the screening group
     3285 women had false positive screenings
     Of those, 1080 had unnecessary surgery, 32.9% of the had their ovaries out
     15% of those having unnecessary surgery had a major complication
     There was no “stage shift” in diagnosis, meaning that the screening group cancers were not discovered at an earlier stage than the usual care group.

So, here’s the take home message.  CA-125 and transvaginal ultrasound are not good screening tests for ovarian cancer for the average women.  Period.  Not only do they not detect cancer earlier, they lead to unnecessary and harmful surgeries.  Period.  The other take home message?  Women were 20 times more likely to die of something other than ovarian cancer.  I can’t stress this enough.  It’s easy to get scared about the possibility of cancer, especially one that there is no good screening test for.  However, ovarian cancer is rare.  Women are much more likely to die of heart disease and stroke than all other cancers combined.  So eat right, exercise, watch your cholesterol, and take your blood pressure medication!


insurance, medicine, primary care

The Problem with Pay-for-Performance

United Health Care has announced that they will be changing how they pay physicians, according to this article.  Currently, most payment is based on what is call a “fee-for-service” plan.  In other words, a doctor does something and bills for it.  There are problems inherent in this system- the main one is that it encourages over-utilization of services.  The doctor has an incentive to perform more services, because that’s how he or she gets paid.

United wants to start paying for “quality of care,” or “pay for performance.”  On the surface, this sounds great, right?  After all, why should a doctor get paid for a bad outcome?

Here’s the problem- people are not widgets.  You can’t plug them into an assembly line and have them all come out the same.  People have individual needs and wants.  They have their own priorities.  They have their own beliefs about health care.

I have many patients who don’t adhere to my treatment plan.  It’s for various reasons.  Sometimes it’s the cost of medications.  For others, side effects are intolerable.  Some have so many family stressors that it’s all they can do to see me once a year, let alone follow all of my directions. Some just don’t seem to care.  Some have a disease process that is so bad that no matter what I do or they do, nothing is going to get better.

In many cases, I don’t follow treatment guidelines.  For example, the patient with severe Alzheimer’s disease, diabetes, and high cholesterol.  Guidelines say they should have a well-controlled blood sugar, be on a statin for cholesterol, and be on an ACE inhibitor to preserve renal function.  Common sense says that the patient is at the end of their life and none of these medications are necessary. 

Here’s what I foresee happening with pay-for-performance.  “Non-compliant” patients will be discharged from practices.  “Compliant” people whose disease is difficult to control will be discharged.  People will be on more medications than they really need, simply to meet an incentive goal. 

Here’s the thing- insurance companies would love it if 1+1=2 all the time.  However, in medicine, that’s not how it works.  Medicine is an art, and everyone needs to be treated as an individual.  Because we’re humans, not robots, this type of plan is doomed to failure.


Changing your Running Stance

There was an interesting article published last month about running.  It came to my attention yesterday via the New York Times

Basically, this study looked at college-aged distance runners and tracked the amount of injuries they incurred.  They found that runners that have a mid-foot strike have a lower rate of injury than runners that have a heel strike.

So, what does this mean?  When most people run, they have a heel strike.  Their heel hits the ground first, then the foot rolls forward and they push off with their toes (mostly the big toe). With a mid-foot or forefoot strike, the ball of the foot comes down first, and there is very little roll of the foot.  The whole foot is lifted off the ground.  This article has very nice pictures illustrating the concept.  Essentially, when hitting with a mid foot strike, there is much less impact to the foot, and, in turn, much less impact to the rest of the body.

I switched to a mid-foot strike a few years ago, following the plan outlined in the book ChiRunning by Danny Dreyer.  I had be bothered by some nagging hip and foot pain, and it really did improve once I switched my stance.  My speed, while never that fast, also improved.

So, the moral of the story is- if what you are doing with your running is working for you, don’t change anything. However, if you are having some foot, hip, knee, or back pain while running, you might want to look further into this.  The ChiRunning site has some great information.

behind the scenes, insurance insanity, primary care

Whoops, They Did it Again!

Medications are not the only things that need “prior authorizations.”  Radiology studies are another one.  Now, if I see a patient and decide they need a CT or MRI scan, you’d think I just order it, right?  Wrong.  I order it.  Then someone from my staff attempts to obtain prior approval for it.  This involves sitting on hold for endless amounts of time, listening to bad Muzak.  Nine times out of ten, the company refuses to grant approval for the study and requires a “peer to peer” review.  This means that I get the chart back and call the insurance company.  Now it’s my turn to sit on hold listening to an instrumental version of  “Born in the USA” while I could be actually seeing patients.  When someone finally picks up, I tell them why I’m calling.  Invariably the person that I’m supposed to speak to is on a Very Important Call, doubtless wasting some other hapless doctor’s time.  So, I give them my number to call me back.  Anywhere between 20 minutes and five days later, they will return my call.  Without a doubt, this call will come while I am performing a gynecological exam on a patient.  I will be interrupted from this and have to leave my poor, chilly patient to take the call.  The call usually goes like this:

Me:  Hi, this is Dr. Nicholas.  I’m trying to get approval for XYZ study.  The indication is blah, blah, blah.

Dr. SellOut:  OK, the study is approved.  The authorization number is 123456789.

Me:  Wait, I didn’t tell you anything that wasn’t on the order and in my note in the first place!  Why did I have to talk to you at all????

Dr. SellOut:  Have a nice day!

So, the study is approved.  Wonderful.  My staff member schedules the appointment and informs the patient.  I get a confirmation of the approval via fax, such as this:

It says “The request for an Abdominal and Pelvis CT has been approved.  It is in effect from January 23 to Feb 22, 2012.”  Note that the letter is dated January 24.

So, all done.  Everyone should be happy, right?  The patient got the CT scan on January 23.  On January 25, we get the following fax:

In case you can’t read it:  “This letter is to notify you that the retrospective request for coverage for this service is denied, and therefore, HPHC will not be responsible for payment for this service.  Reason for denial- Administratively denied for failure to comply with prior notification /consultation requirements.  Provider is liable. There is no member liability for services received.”

Nice, huh?  Translation:  “We approved this but have now changed our mind.  There is no good reason for this, we just felt like it.  You want to get paid for the service you provided?  Tough tootsies.  Pleasure doing business with you!”