If you’re wondering what’s fueling our upward-spiraling Medicare costs, consider the tale of digital mammography.
During the past decade, digital mammography has been stealthily replacing the much cheaper film mammography — even though there’s no good evidence that digital mammograms save more lives.
As the Center for Public Integrity notes in an investigative report published last weekend, “[m]edical researchers say digital mammography is one of a number of tests that, when considered together, are helping drive Medicare costs while doing little or nothing to make Americans healthier.”
The authors of the center’s report, Joe Eaton, Elizabeth Lucas and David Donald, summarize their story as follows:
[H]ospitals and clinics nationwide have spent billions converting their mammography units since 2000, when General Electric released the first digital machine to the U.S. market.
But experts say the newer technology has not been proven to improve breast cancer detection, particularly among women 65 and older who make up the vast majority of female Medicare beneficiaries. …
In fact, for traditional Medicare-aged women, the results of a five-year National Cancer Institute sponsored trial released in 2005 suggest the machines find no more cancers in older women than film mammograms. …
The lack of evidence that digital mammography benefits women over 65, however, has not kept radiologists from using it to screen Medicare patients. An analysis of a six-year sample of Medicare billing data obtained by the Center for Public Integrity and The Wall Street Journal shows that despite its lackluster performance, digital mammography has become the new standard of care in breast imaging for women 65 and older.
Getting Congress on board
According to the center’s report, Medicare claims for digital mammography soared from 426,000 in 2003 to almost 6 million in 2008. That increase can be almost entirely accounted for, the report suggests, by GE’s strategic lobbying of members of Congress (including some well-timed campaign contributions). For, in order to persuade hospitals and clinics to buy the digital machines, which in 2000 cost more than $350,000 each compared to about $75,000 for a film machine, GE had to persuade Congress to pass a law that established a reimbursement premium for digital screening mammograms over film mammograms.
The company succeeded. The national reimbursement rate for a digital mammogram is now $129 versus $78 for a standard film mammogram. And once that premium became law, sales of digital machines soared.
Of course, we health consumers are paying for those higher reimbursements — either through more expensive insurance premiums and/or through our taxes (for Medicare). “A statistical sampling of Medicare data by the center suggests digital mammography may have increased the cost of breast cancer screening by more than $350 million from 2003 to 2008, further depleting the coffers of the rapidly expanding health care program for the aged and disabled that desperately needs to shed costs to survive,” write the center’s reporters.
Nor can we expect the 2010 health-care law to change this situation. “The law makes a push for federally-funded comparative-effectiveness research,” the reporters note, “but is also restricts Medicare from using that research to set pricing or limit coverage of a service.”
Other tests driving up Medicare costs
Although the center’s report focuses on digital mammography, it also mentions two other examples of tests that have driven up Medicare costs without creating better outcomes for patients. One is liquid-based cytology, which was found in a large randomized trial in 2009 to be no better at identifying cervical cancers than the older — and less expensive — pap smear.
The second is the prostate-specific antigen (PSA) screening blood test for prostate cancer. As a routine screening test, this one is highly controversial, and men are now advised by the American Cancer Society and other medical groups to not have the test before discussing the test’s risks and benefits carefully with their physician. (Although, as I reported here in 2009, a study found that doctors rarely give their patients the counterarguments — or “cons” — of the test.) The U.S. Preventive Services Task Force also recommends that men aged 75 and older not have the test at all, as it’s unlikely that at that age they would die of prostate cancer.
“The recommendations, however, did not stem the PSA tide,” write the authors of the center’s report. “Medicare billing for the tests among men 65 and older rose about 18 percent from 2003 to 2006, though the numbers have fallen off some since then. In 2008, about one in seven Medicare-aged men received the test. From 2003 to 2008, PSA tests cost Medicare $372 million.”
With so much money to be made, we can expect these kinds of stories to proliferate. “We are living in a time when a lot of medical interventions have been oversold, and [digital mammography] is another one,” Dr. Russsell Harris, a professor and preventive medicine expert at the University of North Carolina School of Medicine, told the center’s reporters. “What’s happened is that the people who make the machines, who benefit by selling newer machines, have triumphed.”
You can read the center’s full report here.
I wonder if the underwhelming performance of digital mammograms just reflects the longstanding limitations of screening and imaging with this illness that have always existed. Seems like they are offering patients a clearer picture of the chest, when a picture of the chest isn’t the answer in the first place, given an illness that has no discrete “early treatable stage.”
As someone managing the care of two elderly parents, I am concerned that the lobbying efforts of many special medical interest groups have resulted in Medicare reimbursement for items which are profitable,but not proven more effective than alternatives. It is difficult as a child to question (without guilt) a test or therapy that may help ones parents,however. It does seem that the big corporate-sponsored drugs and machines are given more preference in reimbursement than simple therapies/servicews which actually improve the lives of elderly people. Those politicians who are cutting “waste” seem to focus on cutting out actual helpful services and leave in the expensive machines and drugs.
Having experienced the comfort and speed of digital mamos, I am much more prompt about getting in for a mammogram. And I was pretty good about doing it. Anecdotally, I know many who would rarely go in because they experienced such discomfort from traditional mamos. If digital has the effect of getting more women to do the mamos, then it is worth it.
Call me cynical, but in my experience you seldom go wrong following the money.
The efficacy of universal screening for various diseases may be debatable, but the economic impact is not—these tests are a license to print money for those providing the services and equipment to perform them.
With the best will in the world, people will inevitably be influenced by what’s in their interests. It’s human nature. Thus we see vociferous resistance to any suggestion that more tests more often for more people with more expensive equipment may not be medically justified.
As it becomes obvious that our current medical system, with its incentives to do whatever pays the most, is unsustainable, we all need to take responsibility for getting objective information such as that provided here and acting on it when making decisions about our own health. Journalists like Ms. Perry perform an invaluable service.