Medical screening, overdiagnosis, and the motives of for-profit hospitals

Image by @spleenal (Nigel Auchterlounie), who blogs at Spleenal
Image by @spleenal (Nigel Auchterlounie), who blogs at Spleenal

[I don’t seem to be able to display that image anymore, but here’s a link to what I’m talking about.]

This superb graphic was created to dramatize what’s happening these days in the UK, where the National Health Service is being ruthlessly privatized. Here in the US, for-profit medicine is so taken-for-granted that we barely notice it. It’s true, we hear a good deal about conflicts of interest involving pharmaceuticals. Doctors get paid — in one way or another — to increase the profits of Big Pharma, a practice that is detrimental to the financial and/or medical interests of their patients. We hear less about scaring healthy patients into using doctors and services that increase hospital profits (also known as fear mongering). So it was nice to see a recent opinion piece in JAMA that discussed precisely this.

The article, Hospital Relationships With Direct-to-Consumer Screening Companies, was occasioned by a letter that Public Citizen (a consumer advocacy organization) sent to hospitals. In a press release with the title ‘HealthFair Cardiovascular Screening Packages Are Unethical, Mislead Consumers, Do More Harm Than Good,’ Public Citizen explained the medical and ethical reasons why hospitals should end their relationship with HealthFair, a direct-to-consumer (DTC) screening company.

The problem with screening

First, a digression to explain why screening can be harmful.

Screening refers to tests that provide doctors with information about a patient. Most often, screening does not look for actual evidence of disease (a chest x-ray to detect lung cancer would be an exception to this). Screening looks for risk factors (blood pressure, cholesterol, blood sugar level, bone density) that have been correlated with diseases.

The most basic objection to screening healthy, asymptomatic individuals is overdiagnosis. Tests can return false-positives, claiming to detect an abnormality that is not in fact present. They can also uncover minor abnormalities that will never produce symptoms or disease. What then follows is a cascade of events. There will be additional testing, some of which may itself be risky (some tests can result in a stroke or death). The suspected disease will be treated, usually with drugs, which may have harmful side-effects (all pharmaceuticals have side-effects). Patients are subjected to unnecessary anxiety, as well as financial costs. And the cost of health care increases, along with everyone’s insurance premiums.

The risk factors that screening looks for are defined using surrogate endpoints, also called surrogate markers. For example, cholesterol has been considered a surrogate marker for heart disease. There are a number of problems with surrogate markers.

For one thing, while a large clinical trial might find a correlation between cholesterol and heart disease, that finding might not be relevant to a specific individual. People with normal cholesterol levels get heart disease, while many with high cholesterol do not.

Another problem is the way in which revisions to the cutoff point of a surrogate marker — the number that determines whether or not you’ll be classified as at risk — have a history of increasing the number of healthy, asymptomatic individuals who should now consider themselves unhealthy and in need of treatment.

  • In 1997, the cutoff point for fasting blood sugar level (a biomarker for diabetes) was lowered from 140 to 126. This immediately created 1.7 million new diabetes patients.
  • Also in 1997, the cutoff points for high blood pressure (hypertension) were redefined. The numbers dropped from 160 systolic over 100 diastolic to 140 over 90. This created 13.5 million new patients.
  • Following a 1998 clinical trial, the definition of an “abnormal” total cholesterol level fell from 240 to 200. This created 42.6 million new patients, an increase of 86% over the previous number of patients.
  • In 2003 the definition of osteoporosis changed from having a T score (obtained from a bone mineral density X-ray) of less than -2.5 to less than -2.0. This created 6.8 million new patients, an 85% increase in patients.

The redefinition of a cutoff point to a lower level is where overdiagnosis meets financial conflict of interest. Cutoff points are defined and redefined by panels of expert medical specialists. As Dr. H. Gilbert Welch writes:

The head of the diabetes cutoff panel was a paid consultant to Aventis Pharmaceuticals, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Novartis, Merck, and Pfizer—all of which make diabetes drugs. Nine of the 11 authors of recent high blood pressure guidelines had some kind of financial ties—as paid consultants, paid speakers, or grant recipients—to drug companies making high blood pressure drugs. Similarly, eight of the nine experts who lowered the cholesterol cutoff were paid consultants to drug companies making cholesterol drugs. And the first cutoff for osteoporosis was established by a World Health Organization panel in partnership with the International Osteoporosis Foundation—an organization with a corporate advisory board consisting of 31 drug and medical equipment companies.

For more on this subject I recommend both Dr. Welch’s book, Overdiagnosed: Making People Sick in the Pursuit of Health, and the also excellent Prescribing by Numbers: Drugs and the Definition of Disease by Jeremy Greene.

Now, to return to hospitals, DTC screening, HealthFair, Public Citizen, and the JAMA article.

How do for-profit hospitals benefit financially from DTC screening?

Hospitals should serve and benefit the populations they serve. Their goal should be to improve health. Why would a hospital promote practices that, according to Public Citizen, are “potentially harmful and unethical”? As the JAMA article notes, they do this because the hospital can benefit financially in ways that are not at all obvious to the general public. Partnering with a DTC screening company is one way to do this.

Partnering can take a number of forms. A hospital can allow a company such as HealthFair to conduct screening on its premises. It can allow HealthFair to use the hospital’s name in various advertising media (print, online, even direct mail). The hospital’s name can appear on the side of a bus that parks at locations near the hospital and offers screening services. The hospital can promote the screening company on its own website. All of these practices provide medical legitimacy to the DTC screening company.

Just how does this benefit hospitals financially?

To deliver on their missions, hospitals must have a sufficient number of patients use services to fund their operations. In an increasingly competitive health care environment, one strategy to bring in new “customers” is to sponsor outreach programs that can be marketed to the general public as “lifesaving.” …

[H]ospitals … benefit financially when new patients enroll to see their physicians and have follow-up tests and treatments ordered, leading to increased financial reimbursement.

Ideally, DTC screening companies (and hospitals) would disclose the risks and benefits of the tests they perform or recommend. It’s unlikely that a screening company would do this, since “disclosing evidence that shows a lack of benefit, and indeed possible harm, is not in their financial interest.” Lack of benefit and possible harm is precisely what Public Citizen documents in its 20-page letter to hospitals that partner with HealthFair. The letter includes a detailed appendix that reviews “current evidence-based guidelines and relevant scientific literature.” This review documents the evidence and concludes that patients do not benefit from the screening offered by HealthFair.

Are the medical professionals at hospitals that partner with HealthFair unaware of or unconvinced by this evidence? Maybe. Maybe not. The bottom line seems to be that when you’re in the business of for-profit medicine, the opportunity to increase profits can take precedence over the well-being of your patients. It may be too late for the US to avoid the downsides of for-profit medicine. In the UK, however, let’s hope that the medical profession and the public will keep up the good fight against increased privatization of the NHS.

A special thanks to my Twitter buddy @blumo0n (currently tweeting under the name ‘shrapnel’) for bringing @spleenal‘s graphic to my attention and to @spleenal for giving me permission to reproduce it here.

Related posts:
For-profit medicine and why the rich don’t have to care about the rest of us
From healthism to overdiagnosis
There’s more to life than the pursuit of health
Overdiagnosed and overprotected children
Screening for cancer and overdiagnosis
Creating an epidemic of cancer among the healthy
The downside of overly aggressive cancer screening
Drug shortages: “We are talking about people’s lives; this is not a cell phone contract”
Patient safety and corporate profits
Mental illness in college students: Overdiagnosed

Image source: Artist: @spleenal (Nigel Auchterlounie), who blogs at Spleenal. This particular image can be found on Twitter.

Resources:

Erik A. Wallace, John H. Schumann, Steven E. Weinberger, Hospital Relationships With Direct-to-Consumer Screening Companies, Journal of the American Medical Association, September 3, 2014, Vol 312 No 9, pp 891-892

HealthFair Cardiovascular Screening Packages Are Unethical, Mislead Consumers, Do More Harm Than Good, Public Citizen, June 19, 2014

H. Gilbert Welch (2011), Overdiagnosed: Making People Sick in the Pursuit of Health

Jeremy Greene (2008), Prescribing by Numbers: Drugs and the definition of disease

Nigel Auchterlounie (2009), Spleenal

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5 Responses to Medical screening, overdiagnosis, and the motives of for-profit hospitals

  1. Hello Jan and thanks so much for this comprehensive overview of such a wide-ranging and important subject in healthcare. When you write: “…cholesterol has been considered a surrogate marker for heart disease”, it’s important to also remember the furor that greeted the American Heart Association/American College of Cardiology’s revised cardiovascular guidelines last winter (both non-profit organizations, by the way, that are coincidentally heavily supported by drug companies).

    The new guidelines essentially tell docs: from now on, forget about your patients’ LDL cholesterol numbers (this after decades of training patients to focus very carefully on their LDL numbers!) But it’s now all about our cardiovascular risk factors instead – by using a controversial new risk calculator that basically determines statin prescriptions are appropriate for anybody with a detectable pulse. As Stanford cardiologist Dr. Mark Hlatky wrote at the time:

    “The risk level is now set so low that many people who have optimal risk factor levels would be targeted for statin treatment simply on the basis of their age.”

    So what’s a poor confused patient supposed to do when people with the letters M.D. after their names cannot seem to agree on new treatment guidelines – or DTC screening companies that are in bed with hospitals?

    Here in Canada, many of us are as concerned about the insidious move towards privatizing our health care system as our U.K. counterparts are.

    regards,
    C.

    • Thanks for your comment, Carolyn. Funny you should mention that. I actually had included that as the last item in my list of how guidelines change, but I took it out because I felt the post was getting too long.

      To be fair, a revision of the cutoff point occasionally creates fewer patients at risk. In 2013, new cholesterol guidelines were released. Instead of recommending treatment (statins) for patients with an LDL cholesterol level of 70 milligrams per deciliter (mg/dL), the number went up to 190 mg/dL. (The guidelines are much more complicated than that one set of numbers.) As one doctor commented, referring to the new calculator that determines who should be treated, “I just hope it doesn’t make people mistrust the guidelines.”

      I was very aware of it because I was told two years ago that my LDL cholesterol was too high, and I completely changed my diet (and my LDL). So now they tell us “nevermind.” You’re absolutely right: what’s a poor confused patient supposed to think?

      Jan

  2. While it’s true that the revised guidelines’ arbitrary LDL number was higher, the overall risk calculator actually creates far more “patients at risk” – hence the controversy last winter! And as for Dr. LeWine’s comment: “I just hope it doesn’t make people mistrust the guidelines”…. oooops, too late.