New Pap Smear Guidelines - Rationing Healthcare or the Right Care?

The American Congress of Obstetricians and Gynecologists (ACOG) recently reiterated their position that Pap smear should be performed on healthy women starting at age 21. This is different from the past which recommended screening for cervical cancer at either three years after the time a woman became sexually active or age 21, whichever occurred first.

How will the public respond to this change?

Over the past year there have been plenty of announcements from the medical profession regarding to the appropriateness of PSA screening for prostate cancer and the timing of mammogram screening for breast cancer. Understandably some people may view these changes in recommendations as the rationing of American healthcare.

They should instead, however, welcome these advancements. Doctors becoming even better at understanding which screening tests work and which ones don't.

Doctors have discovered that for cervical cancer, which is detected by Pap smears, a significant risk factor in infection from the human papilloma virus (HPV). HPV is the most common sexually transmitted disease and aside from causing cervical cancer are also the cause of genital warts. Women under age 21, who are healthy and do not have a compromised immune system from HIV or organ transplant, rarely develop cervical cancer from HPV infection.

Unlike the past when women needed annual pap smears, advances in screening with new liquid-based Pap smears as well as screening for HPV allows women to be checked for cervical cancer every other year. Women age 30 and older who have had three normal pap smears in a row can have Pap smears every two to three years with a Pap smear or every three years with a Pap test and HPV DNA screening.

If all doctors recommended these interventions, this would reduce the number of Pap smears needed by 50 percent. The newest cervical cancer screening method would be far better as it identified which women were at risk with better precision and information than the past. By doing fewer unnecessary Pap smears, doctors are now free to address other problems as well as begin to take on the millions of Americans who will have health insurance due to reform.

The question is will they do it? Will women accept the new changes in screening intervals?

Research shows it takes about 17 years before results of studies and guidelines become commonly practiced in the community. One study showed primary care doctors were not particularly good at screening for colon cancer though new guidelines have been around for a decade.

It's easy to blame doctors for being slow to change. It's easy to blame patients for being slow to change. Many of my patients still demand an annual pap smear even though HPV DNA testing is something my colleagues and I have practiced for years.

The fact is that change is hard unless of course you are new to something. As my five year old daughter proudly told me recently there are exactly EIGHT planets not nine in the solar system.

For the next generation of women, they will not need Pap smears until age 21. They can be safely screened every other year. There is a chance that none of them will never develop cervical cancer as since 2006, HPV vaccines exist for individuals age 9 to 26 that immunize them from the subtypes of HPV that cause cancer.

These women won't get upset. They won't get worried.

They know this is the right care. This is not rationed care.

That is, of course, until the next revision in the guidelines and recommendations.

Lack of Healthcare Reform Means that the American Dream is Dead.

It appears that the American Dream is dead as the Democrats have essentially no chance in passing some sort of healthcare reform package. The stunning loss of the senate seat held by the late Ted Kennedy has now given the Republicans the ability to filibuster any significant healthcare legislation.

More disappointing is that Americans seem willing to accept the fact that they can live without healthcare. In a blog at US News and World Report titled 21 Things We're Learning to Live Without, besides abstaining from cable TV, a home phone, prepared foods, and lattes, healthcare was also on the list. Millions of Americans are apparently "simply hoping they don't get seriously ill or hurt." How can this happen is supposedly the wealthiest nation in the world? Too many Americans as a result are literally one illness or accident away from financial ruin as medical costs are the leading cause of personal bankruptcy.

While President Obama and the Democrats no doubt will try to salvage what they can from their hard work over the past year, they need to be thoughtful about their future proposals. Though the public doesn't like the thought of insurance companies turning away those with pre-existing conditions, the fact is that this practice exists because we don't mandate everyone have health insurance. As George Halvorson, CEO of Kaiser Permanente, noted to make healthcare affordable a double mandate must apply - everyone must sell (that is health insurers must sell coverage to everyone who desires it) and everyone must buy (all consumers must purchase). Otherwise, those who are healthy would not participate and instead would wait until they needed it. Those who are already ill will purchase health insurance. As a result, insurance companies would only receive payments from those who need medical care, which can't possibly cover costs of chemotherapies and hospital stays which are in the tens of thousands per treatment. Since the healthy don't subsidize the sick, insurance companies would simply go bankrupt.

With the President and his Democratic party concerned about a Republican resurgence, he has already refocused his attention on large institutions like banks and redirecting the populace anger there rather than working on meaningful change. He may try the same tactic on insurers in an effort to get some healthcare reform passed.

In doing so, he may simply ignore the truth of the double mandate and make insurers not only cover everyone but also have the federal government set the rates. President Obama knows of course that it would only be a matter of time that the government would take over healthcare as insurers would have no choice but to pull out in this financially unsustainable model. If a single payer system occurs be prepared for rationing of medical care. Imagine long waiting lists to see a specialist, getting surgery done, or wondering if a treatment might be approved. Certainly some of these problems occur already with private insurers, but envision if the healthcare system was run by the DMV. Is this actually better?

It's equally as unfortunate and more disappointing that the Republican party over the past year essentially only had one mission - derail any proposals from the Obama administration. Without healthcare reform to make insurance coverage more affordable to employers, families, and individuals, America will no longer be viewed as the vibrant superpower nation it has been over the past couple of decades but a country unable to provide the basic healthcare needs to its populace because its politicians were too paralyzed to do anything but score political points for the next election. Because of their failure to lead, it is increasingly clear that in the United States healthcare coverage isn't a right but a luxury.

If Americans and employers are constantly worried about saving money for a future expensive illnesses or medical problems, then when will they ever feel secure enough or freed enough to take risks, invest, and dream?

Can Doctors Provide Rational Care or Cave In? H1N1 Experience with Public Health Indicates Latter

As the country discusses providing everyone with health insurance, an even more important conversation is how to slow the rise of healthcare costs. Many studies and research point to the ability of doctors to remove waste by not performing unnecessary tests or procedures and not prescribing the latest medications which are proven to be no better than generic versions. There is a belief that much of this additional cost is due to the fee for service reimbursement system where doctors get paid more to do more.

For example, spending 30 minutes on nutritional counseling, weight loss, and exercise for one patient with hypertension doesn't pay as much as prescribing blood pressure medication for three patients in 10 minutes. In the fee for service environment, volume is key, not necessarily providing the right care or the most rational care. A recent Newsweek opinion piece by an emergency doctor showed how he evaluated a patient appropriately for a recent head injury, discussed the plan with the family, and arranged follow-up with the pediatrician all without getting a CT scan of the head. Result? Patient did fine. No radiation exposure to the brain. No additional cost to the healthcare system, insurer, or family. Everyone benefited.

While the example isn't rare, it also isn't common. Some 30 percent of tests or procedures performed in this country have been suggested to be unnecessary and added no value to improving patients' quality of life or outcomes.

In other words, if we removed the fee for service reimbursement system, then doctors would prescribe only the right care. Not too much or too little, but just right.

Or would they?

Recent articles should make us think twice. The H1N1 virus which has been demonstrated to affect those under age 25 years old and pregnant women disproportionately than the general population now has a vaccine available, albeit in short supply. This limited supply has been given to individuals not deemed at high-risk for adverse outcomes by CDC.

While the issue might be that some public county clinics received more vaccine than others (a systems or distribution problem), the bigger question is whether public county officials and doctors are willing to have honest and frank discussions about a person's need for the vaccine. Unlike doctors in the fee for service environment, these providers don't get paid more to do more. Since compensation isn't an issue, then can they talk through the fear that people have and provide the appropriate care?

Answer? Unfortunately no. Public health officials don't want to be the police and determine who should justifiably get the vaccine and who should be turned away.

In other words, if people want it, then they will get it. If public health officials can't say no appropriately, then can we expect much better for doctors in the future? Even if the fee for service reimbursement structure is removed, unclear if that will ever happen, will doctors provide rational care and advice or cave in when patients demand prescriptions based on television ads or care recommended by celebrities?

As I received my vaccine at a flu clinic, there were nurses asking each individual in line what vaccine did they want. The nurses appropriately advised those not in the high-risk groups that they would only receive the seasonal flu vaccine and not the H1N1 vaccine. There were no fights, outbursts, or fear. Patients understood that they were getting the right care. Not too much and not too little, but just right.

If America is going to solve the affordability issue of healthcare, then doctors will need to lead the way.

Based on the public clinic officials' performance, I'm even less optimistic about the medical profession's ability as a whole. While I have great confidence in my fellow medical school alumni from the University of Connecticut School of Medicine, the colleagues I work with at the Permanente Medical Group as well as the many medical bloggers I've encountered (many who follow me via Facebook or Twitter - thanks everyone!) , I have real concern about many doctors nationwide and specifically on their ability to provide rational care and not to cave in and take the easy way out when making decisions about medical care.

What does this ultimately mean? Without doctors leading the way, the only choice left is government run healthcare. If doctors can't say no based on scientific and medical evidence, then Uncle Sam will say no. Don't say I didn't warn you.

Evidence That Doctors Will Not Support Healthcare Reform

While doctors are interested in covering all Americans with health insurance, universal coverage alone will not resolve the healthcare crisis. One of the major cost drivers in healthcare is due to more imaging tests, use of expensive medications, as well as more medical interventions which actually don't result in better outcomes.

This has been well described in various articles and books.

Despite our perception as physicians, it isn't necessarily defensive medicine and ordering more tests, procedures, and imaging that is driving overall healthcare costs, but is the reimbursement system. It rewards volume over quality and is particularly true for specialties that can increase volume. This is why primary care doctors have not seen increases in compensation and medical students are flocking to other specialties like dermatology, radiology, ophthalmology, among others. Primary care doctors can only increase volume by seeing more patients. Other specialties can improve compensation and volume by doing more surgeries and procedures, which in many instances are questionable if they are truly needed, effective, or even better than non-invasive treatment or watchful observation.

So it comes as no surprise that the New England Journal of Medicine's article - Physician's Beliefs and U.S. Health Care Reform - A National Survey finds doctors agree in abstract with universal coverage, but when asked to make that happen by asking themselves which expensive treatments really work and which are unnecessary that they walk away from the responsibility. Excerpts from the article:

Although physicians tend to agree in the abstract that health care resources should be distributed fairly, they may be unwilling to endorse concrete policies that expand coverage for basic health care by limiting reimbursement for costly interventions. And despite widespread discussions about using cost-effectiveness data or comparative-effectiveness research to guide clinical decisions, physicians may remain skeptical about such practices.3,4 Thus, physicians may not be willing to take on the role that the President and health policy advocates want them to play.

...surgeons, procedural specialists, and those in nonclinical specialties were all significantly less likely than primary care providers to favor reform that expands access to basic health care by reducing reimbursement for expensive drugs and procedures...

First, the President, lawmakers, and reform advocates can vigorously engage physicians in deliberations on health care reform, cognizant that most physicians see it as part of their professional responsibility. However, more controversial elements of reform, such as limiting reimbursement under Medicare (i.e., expanding the ranks of the underinsured), using cost-effectiveness data in treatment decisions, and limiting reimbursements for expensive drugs and procedures — all of which are elements of current reform proposals — may face serious opposition from segments of the medical profession.

In other words, you can't have your cake and eat it too. If we as a nation wish to expand coverage so that it is universal and everyone has health insurance, then we can't have every test, procedure, medication, and intervention that we want. However, that really isn't the right way to look at solving the problem.

The right question to ask is do we as a nation need every expensive test, procedure, medication, and intervention when others that are less costly but just as good work (comparative-effectiveness research - think Penicillin is still used for strep throat and has been around for over 60 years)? If we agree on the latter, then the problem becomes those medical specialties that benefit from more volume will see a pay cut.

When the abstract of universal coverage meets the reality of taking money away from someone's pocketbook, in this case more specialty doctors than primary care doctors, expect the discussion to become vocal and talk to elevate about rationing care rather than providing rational care. Healthcare reform does NOT require rationing.

Healthcare Reform Does NOT Require Rationing

The Washington Post printed a piece titled, "In Retooled Health-Care System, Who Will Say No?". Obviously a very tricky question to answer. The healthcare system without significant changes will generate costs out of control.

The federal government is loathe to do what England has done by indicating what is and isn't covered.

Patients certainly don't know what tests, imaging studies, or medications are needed to stay healthy or get better. Often they are fooled by slick advertising as well as the false belief that more is better (perpetuated by medical dramas like ER and House).

Insurance companies have tried, but given their past track record it is doubtful they can lead the change.

So who will say no? It's the doctors. Frankly it isn't as much as saying no as it is about refocusing what patients really want. What they really want is just the tests, imaging studies, and medications that they need to get better and well. They really don't want everything under the sun.

Research shows that we do too many tests, procedures, and interventions and the outcomes are actually worse! There is plenty of opportunity to still deliver high quality care without falling into the trap, which we are all victim to that newer is better. Don't buy this lie!

The problem is that the reimbursement system rewards doctors to do more. Until that changes, nothing will change. If reimbursement does change, then will doctors have the ability to counsel their patients on what the right care is when in the past, it was wrongly believed that more is better?

Save Money on Medical Costs - 10 Tips from Money Magazine

The July issue of Money magazine article "Beat the rising cost of health care" has a quote from yours truly!

• Finally, ask about alternatives, says Davis Liu, a family doctor and the author of "Stay Healthy, Live Longer, Spend Wisely." For example, your doctor may suggest an MRI to figure out why your back is hurting. But if you push back a bit, she may also tell you that you can first try back exercises for a few weeks and see if the pain goes away on its own. It very often does.

Overall great tips. Without serious healthcare reform, the brutal reality is this. We are already rationing healthcare in this country. It's not based on your age, health, or research. It's based on your ability to pay.