Category: Health

Medical paperwork is a world of co-payments and co-insurers, deductibles, exclusions and contracted fees. Nothing is as it seems: patients receive statements that often do not reflect what is actually owed; telephone calls to customer service agents are at best time-consuming and at worst fruitless. The explanations of benefits that insurers send out — known as E.O.B.’s — are filled with unintelligible codes.
The system is so impenetrable that it mystifies even the most knowledgeable.
”I’m the president’s senior adviser on health information technology, and when I get an E.O.B. for my 4-year-old’s care, I can’t figure out what happened, or what I’m supposed to do,” said Dr. David Brailer, National Coordinator for Health Information Technology, whose office is in the Department of Health and Human Services. ”I can’t figure out what care it was related to or who did what.”
Dr. Blackford Middleton, a professor at Harvard Medical School with special training in health services research, said he did not fare much better than Dr. Brailer.
”I understand the words of diagnoses and procedures,” he said. ”But codes? No. Or how things are paid or not paid? I don’t understand that.”
Dr. Brailer said he often used an analogy to describe the current state of medical billing.
”Suppose you walk into a restaurant,” he said, ”and you don’t get a menu, you don’t get any choice of what food you’ll eat, they don’t tell you what it is when they’re serving it to you, they don’t tell you what it’s going to cost.”
”Then, weeks or months later, you get a bill that tells you all the food you ate and the drinks you had, some of which you remember and some you don’t, and although you get the bill, you still can’t figure out what you really owe,” Dr. Brailer said.
Some people make valiant efforts to sort through bills and claims, but end up throwing up their hands; others ignore them, until they are pursued by collection agencies; still others, basically healthy but weary at the prospect of a paperwork fusillade, stop going to the doctor altogether.

KATIE HAFNER. “Treated for Illness, Then Lost in Labyrinth of Bills.” The New York Times (October 13, 2005): A1.

Unfortunately some cancer tests do a lot more good for doctors’ revenues than they do for patients’ longevity:

“The improvement in long-term mortality may be due to the higher proportion of small or slow-growing tumors being detected, which means you start counting earlier,” says Dr. Jaffe. That’s why longer survival, measured from the time of diagnosis, is a misleading measure of progress against cancer, and no substitute for reductions in mortality.
The more scientists study cancers, the more indolent ones they discover. Researchers in Japan, for instance, find that CT scans detect almost as many lung lesions in nonsmokers as in smokers. But since nonsmokers have a mortality rate from lung cancer less than 10% that of smokers, the vast majority of what CT scans picked up would never have progressed to anything life-threatening. And a Mayo Clinic study found that although X-rays detect lung cancers at earlier stages, and lead to more five-year survivors, early detection does not lower death rates.
For colon cancer, the fecal occult blood test “does decrease your risk of dying of this cancer,” says Dr. Kramer. “But for colonoscopy and sigmoidoscopy, which appeal to our intuition [about early detection], the evidence is not great.” They pick up polyps earlier, but not all polyps become cancers, “and we don’t know what proportion would lead to death.”
The Pap test for cervical cancer has saved lives, but many of the abnormal cells it finds wouldn’t go on to become cancer. Most women with low-grade or even high-grade lesions would have been fine anyway. Similarly, the PSA test for prostate cancer picks up tumors that are biologically nonaggressive.
The discovery that many tumors are innocuous casts doubt on the value of new screening tests. “You may fool yourself into thinking a test is twice as sensitive,” says Dr. Kramer, “but the only extra cancers it picks up are those that wouldn’t have harmed the patient.

SHARON BEGLEY. “Early Cancer Detection Doesn’t Always Give Patient an Advantage.” The Wall Street Journal (August 26, 2005): B1.

According to a study published in the July 13, 2005 Journal of the American Medical Association (JAMA) by Dr. John Ioannidis, almost a third of the medical studies included in his sample, were eventually either contradicted by subsequent studies (16%) or else required significant modification. (One media report summarizing the study appears at: http://www.newsday.com/news/health/ny-hsdrug4348592jul19,0,2629446.story?coll=ny-health-headlines)
This is only surprising in the face of the certainty with which the media and parts of the medical establishment, totally embrace each new study as it appears. Perhaps the tentativenss, and revisability of medical research argues for allowing patients more choice in their treatment?