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  • 1.  H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 10:35
    Hi All,

    Dr. Gil Welch and Dr. Barry Kramer, former director of the National Cancer Institute's Division of Cancer Prevention, posted this essay today in STAT:
    https://www.statnews.com/2022/01/12/medicare-shouldnt-cover-liquid-biopsies-early-cancer-detection/

    As I mentioned earlier, just the prospect of Aduhelm use had Medicare substantially raise premiums this year. Blood testing like that advocated by the American Cancer Society 
    would dwarf those medication-related costs with a cascade of needless and harmful diagnostics and therapeutics. 

    As someone who has, since my time with the National Health Service Corps, cared for a patient panel virtually all with Medicaid and Medicare coverage, I find the ACS's argument about this testing technology solving inequities to be especially galling and misleading.

    I hope this can be an active area for SIDM to weigh in as Drs. Welch and Kramer have today.

    Best,
    Steve

    H. Gilbert Welch is a general internist, senior investigator in the Center for Surgery and Public Health at Brigham and Women's Hospital in Boston, and author of several books, including "Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care" (Beacon Press, 2015). Barnett Kramer is an oncologist, member of the Lisa Schwartz Foundation for Truth in Medicine, and former director of the National Cancer Institute's Division of Cancer Prevention. Both are Medicare beneficiaries.

    ------------------------------
    Stephen Martin, MD EdM
    UMass Chan Medical School
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  • 2.  RE: H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 14:00

    Steve,

    Thanks for sharing! This is an extremely important issue requiring a bright spotlight from medical leaders, quality/safety experts and patient advocacy groups.   Since we spend the most in the world on healthcare yet are ranked 37th on basic health measures it is easy to conclude that more is not necessarily better.  It's easy to see how rushing into "liquid biopsies" will evolve into a medical and financial disaster. Those with vested financial interest will leverage the superficial thinking and misunderstanding of "who wouldn't want to know about their cancer early?" to force the politicians and then CMS to reimburse these new tests. 

    This again raises the issue of is overdiagnosis a diagnostic error problem?  It really seems impossible to separate the two missions.  I agree that SIDM should weigh in on the dangers of overdiagnosis and screening without a grounded risk-benefit analysis.  I hope the SIDM Board does develop a policy recommendation on this. 

    Thanks again for bringing this to the list!

    Best

    Art

     

    Art Papier MD  Chief Executive Officer


    email apapier@visualdx.com

     

     




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  • 3.  RE: H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 14:13
    Thanks, Steve!  

    This article is nicely written, clear, authoritative, and presents very sound reasoning on the topic.  The downside of the current bias toward overtesting is rarely addressed and is poorly understood by the public (and even by physicians!).  It was the focus of a prior SIDM keynote speech a few years ago, given by the head of the National Cancer Institute, who focused on the over-diagnosis of non-harmful "cancers" that are detected by screening asymptomatic patients, thus leading to over-treatment--with it's own morbidities, patient harms, and an undue financial burden to those patients.

    Mike



    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  

    1571679014277



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  • 4.  RE: H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 14:21



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  • 5.  RE: H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 14:55
    Thanks, Edward!  Thanks, Art!


    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  

    1571679014277



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  • 6.  RE: H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 14:47

    Historically, I think the most egregious examples came from the urology community on overuse of PSA (though I think AUA has been quite responsible on the topic in recent decades), and mammography, where I see more of a mixed record among breast surgeons and radiologists. Given that history, maybe it's inevitable that my own laboratory medicine community is being the bad guy now (in partnership with biotechs, investors, and sadly the ACS who I thought had turned the corner on this issue a few years back).

     




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  • 7.  RE: H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 14:51

    Since I just cast aspersions at (some) radiologists, I need to now atone by acknowledging the ways in which radiology professional societies criticized whole-body CT/MRI screening centers when they started to get popular about 20 years ago. That particular industry never really took off, maybe because it was largely direct-to-consumer, so insurance payments never followed. (And consumers ultimately didn't see the value of paying thousands out of pocket for something with no proven benefits.)

     




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  • 8.  RE: H. Gilbert Welch and Barnett Kramer: The crazy confluence of Congress, liquid biopsies, Medicare, and health inequities

    Posted 01-12-2022 15:06
    No offense taken, Brian!

    Radiology & imaging for screening has been a huge source of this problem.  Many of us in radiology are skeptical of the true value of annual CT for lung cancer screening and the recent augmentation of screening mammography in many centers to include 3D tomographic imaging--which dramatically increases the cost, radiation exposure and effort/resources consumed, but without measurable benefit to patients' survival.  

    There is also "hidden" use of imaging for what essentially amounts to widespread screening.  Current estimates of over-use of advanced imaging run in the range of 30%, mostly CT and MRI being used without an appropriate symptom or "target," so in essence, that is an additional ~30% "screening" use (statistically the same as screening an unselected population with CT or MRI).  We radiologists discover many "incidental" findings on these studies, which then carry a lot patients down the rabbit hole of invasive/expensive/painful workup, which adds to patient suffering and harm with very low yield in real benefits or lives saved.

    Art is correct--we need to really look at this issue rigorously, and I think this would be an excellent "crusade" for SIDM to take on.  Diagnostic safety includes safety from over-diagnosis and over-treatment (and, I would suggest, from over-screening as well).

    Mike



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