S(uch) S(trange) M(edicine)

SSM Health, one of the nation's largest hospital and health care systems, has adopted a statement of values which includes the following:

• Excellence
  We expect the best of ourselves and one another.
• Stewardship
  We use our resources responsibly.

I'm sure they do many good things (and have gotten lots of awards) but there is one exceptionally bad thing they are doing that deserves review.  It's outlined in this blog post by Al Lewis and Vik Khanna.  Here are some excerpts:

The pitch is that Vik could get a package of six screenings, available for a limited time for the promotional price of $179 (total “value” $2,300), with an additional Know-Your-Numbers lipid panel assessment for just $99. Combine both offers and get an additional $20 off, with a total price of just $258. The six-test package of screenings includes:

• Echocardiogram ultrasound
• Stroke/carotid artery ultrasound
• Abdominal aortic aneurysm ultrasound
• EKG
• Peripheral artery disease (PAD) test
• Hardening of the arteries test (also called the Arterial Stiffness Index or ASI)

What's the problem?  The problem is that these tests are not only generally useless, absent a clear case of medical necessity, but they are also affirmatively not recommended by those organizations who study such things.  The authors note:

For the sake of consistency, we look first to the published recommendations of the United States Preventive Services Task Force (USPSTF) which is the closest thing we have to an independent, credible arbiter of data on preventive services. In cases where the USPSTF has not made a recommendation, we look to the literature.

Abdominal aortic aneurysm ultrasound: Rated “B” only for men aged 65 to 75 with a history of smoking. It’s a C for men in that age with no smoking history, “I” or inconclusive for women 65 to 75 who’ve smoked, and a D (more harmful than helpful) for women in this age range with no smoking history.

Stroke/carotid artery ultrasound: rated a D for all adults who are asymptomatic. Someone with symptoms doesn’t need a screening; they need a workup and therapy.

Echocardiogram ultrasound: the USPSTF doesn’t even have a recommendation on this, so we look to the literature. A large, long-term study from Norway, published in JAMA Internal Medicine in 2013, concluded that echo has no prognostic value. This jibes with the recommendations of the American Society of Echocardiography, articulated at Choosing Wisely, that echo is overused even in people who are symptomatic and should be avoided in people who have no reason to get one.

Electrocardiography or EKG: USPSTF rates this a D for adults with no symptoms and of inconclusive value even for people in moderate or high risk categories.

Peripheral artery disease (PAD) test: The USPSTF rates this screen as I or inconclusive. They do say, however, that the incidence of PAD in the general population is unknown. While this testing has value in people who are symptomatic, they were not coy about its value in people with no symptoms: “The USPSTF found no evidence that screening for and treatment of PAD in asymptomatic patients leads to clinically important benefits.”

Hardening of the arteries test (also called the Arterial Stiffness Index or ASI): The USPSTF has no recommendation on this. But, the American Heart Association, which typically doesn’t softsell cardiac goods and services, completely disses this test [as] not recommended (Class III).

The authors suggest that commercial interests might be prompting these activities by SSM:

They . . . understand medical guidelines.  They choose to ignore them, in order to create followup revenue for the (mostly false) positives that these tests will inevitably reveal.  And the reason they are practically giving them away is that they not covered by insurance because the Affordable Care Act requires health plans to cover only screens that are A or B rated by the USPSTF.  However, all the followups will be well-reimbursed.

I reach no conclusion except that this program violates SSM's statement of values:

• Excellence
  We expect the best of ourselves and one another.
• Stewardship
  We use our resources responsibly.