Can We Have Our Billions Back Please?
Barrett's Esophagus: Another Disease Focused Failure
Why would an advocate for basic health access keep hammering on disease focus? The answer is simple. For decades we have more different researchers and subspecialists creating more reasons to spend dollars anywhere but on basic health care services, especially services needed by over half of Americans.
Disease Focus is Way Out of Hand
As long as those that control health care find hundreds of reasons to send more billions to each new reason, the United States will never get around to caring for 160 million or more Americans already left behind in even the basic services.
Insurance companies do not care about higher costs. They just collect more dollars - more to cover the increased costs and even more to cover the possibility that the costs will be higher. According to the American Medical Association report, over 70% of health care markets, do not have enough competition to keep them from doing this. They have wiped out the competition. More dollars turn into more dollars and then we need to train even more subspecialists costing more dollars while our economy falters from the fast rising health care costs. More subspecialists with higher incomes divert us from primary care workforce not only in physicians but in nurse practitioners and physician assistants.
Attempting to Kill Off a Killer
For years we have feared Barrett's esophagus. After all Barretts is only one small step away from esophageal cancer. We get acid sloshing up into the esophagus, the esophageal tissue changes, and then there is esophageal cancer. Tens of thousands have had referrals to GI docs to have endoscopy. Even more have been self referred back for future endoscopies and more biopsies. We have some patients getting endoscopy each 6 months because they are considered high risk. One problem with all of this is that esophageal cancer still continues to kill. Testing must actually work to decrease death from cancer.
No studies have demonstrated any impact of this substantial investment in more and more upper endoscopy. The lack of evidence has not prevented widespread application. Physicians trained to stamp out disease found a disease to stamp out and attempted to stamp it out.
It is hard not to get emotional. Esophageal cancer is one of the nasty cancers that eat away from the inside. By the time the cancer shows up, it has often spread. It is easy to see why patient and physician would want to prevent a cancer or identify one early. I feared Barretts and esophageal cancer in my father for years.
Each episode of heartburn in my father seemed in my mind to head him toward this area. I was frustrated with him for not going. I was frustrated with his physicians, some of my earliest physician mentors, for not scoping him. I got my own upper scope for the same reasons. It turns out that they were right and I was wrong. As it turns out, these recommendations were based on bad data.
High Cost and Low Yield
This particular attempt to eliminate cancern has been very costly for not much gain. The reason is that the risk of progression of Barretts to esophageal cancer is much lower than previously indicated. Higher risk estimates for annual change mean that screening tests need to be more often. Lower risk translates to less often for the test, or not at all.
The previous estimates were about 1 out of 200 progressing to esophageal cancer each year. As it turns out, a number of studies now indicate less than 1 in 800 will progress. This means you can wait more years between test, or not test at all.
Billions Later We Have the Answer
Now we find out that the best policy should have been no widespread screening. Limited screening should have proceeded as part of a research protocol. Experts remind us that no study has yet demonstrated that screening has actually resulted in lower death rates.(David A. Johnson, M.D.)
More scopes from above and below have also cost billions of dollars in the cost of procedures, in the additional GI specialists required, and in terms of primary care workforce. More IM graduates to GI means less internists for primary care. Also about 3% - 4% of nurse practitioners have moved to GI despite primary care training. We all pay more to health insurance for scopes and more scopes.
Thanks to all 12,000 who have visited Basic Health Access in 2011.
Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
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