Diagnostic Imaging
December 2002

CONSUMER SCREENING

Societal factors portend great future for CT screening exam

With big spending on gym memberships and vitamins, what's another $500 for a scan?

Many articles have dealt with the merits and demerits of screening, meaning imaging studies that may be self-referred to look for occult conditions that could affect the life or well-being of the individual being screened. The economics of screening centers and the technology involved have also been discussed. But macroeconomic and societal factors also drive the screening phenomenon.

Because health is so pervasive, we lose sight of the fact that it is the biggest news story in the country. It is hard to open a consumer magazine without health articles in it. This is the story of the day, every day. Not many people expect to be blown up by terrorists, not everyone lost money on Enron or Worldcom, but everyone knows they will die. Delaying this moment has become the national preoccupation. The expectation is not only a long life, but also a healthy life.

Wellness has become an entitlement, lowering the threshold for what is an unacceptable condition. When I was growing up in Buenos Aires, families in my neighborhood were either salaried or had small businesses. The salaried people were paid at the end of the work day, in cash-no disability, vacation, or sick leave. If you did not show, you missed that payment. In this environment, knee pain, elbow pain, shoulder pain were not heard of, and back pain was only commented on. When someone stayed home, we knew that person was very ill. Children with a bad cold were allowed to stay home, but parents with a cold continued to go to work or take care of the house.

As a society becomes affluent, it can afford to lower the threshold. Leisure time becomes available, and it can be used for self-care, whether this is nursing a mild condition, exercising, or visiting doctors. When income exceeds what is needed for the basics, spending on health and wellness becomes possible. Medicine today, in terms of money spent, does not aim at life-threatening diseases as much as it maintains lifestyle. Big sellers like Allegra, Viagra, Lipitor, and Prozac do not save lives. MRI without sports medicine and musculoskeletal work would be a commercial liability to manufacturers.

SUPPLY AND DEMAND

The demand for health services is infinite. No matter how much money is made available to the system, it can be absorbed and more requested. This has caused the public and private payers of healthcare services to create rules that limit access to services. The rules are predicated on using the available resources to do the best job for the population being served, not necessarily for the individual. This approach creates a sense of neglect in all of the population, along with frustration and mistrust.

This mistrust draws reinforcement from various societal sources. The loss of trust in government that followed the Watergate-Vietnam era carries to other establishment icons, including medicine. Here it manifests in mild form as a feeling that doctors do not care for patients but only for money or as an extreme view that doctors know how to cure major diseases (usually cancer is mentioned) but do not want to because they would face financial ruin. Absurd and implausible as this extreme view is, it is held across a wide swath of society. The medical establishment is seen by many as unresponsive at best and threatening at worst, and the reaction is to take control over one's own healthcare.

In an era when knowledge is wider and deeper than it has ever been, and when it is more easily accessible than ever, obscurantism flourishes. Individuals turn to quackery such as chelation therapy, radionics machines, and dietary supplements that are of no value, or worse, are dangerous. The gullible are so numerous and well placed that governmental agencies, which would close down a Merck or GE that made the same outrageous claims for its products, allow the unscrupulous who take care of the credulous to operate with impunity.

Quack technologies have found a market partly because the technologies that we know work are so controlled and regulated. If someone worried about having a stomach cancer because of family history could walk into a CT or MRI clinic and have a scan without waiting months for an appointment with a primary-care physician, then weeks for the provider to approve the request (if it is approved), then several more weeks for the scan itself, that individual would not be tempted by Dr. Gary's radionics machine. The very process of establishing standards, quality control, and appropriate access criteria helps create an environment where quacks can milk the gullible.

The demand goes beyond the worried well. Seventy-five to 120 million people need to be examined every five to 10 years if we are to substantially reduce colon cancer deaths. Smoking is coming back among young women, young blacks, and many immigrants who bring their cigarette consumption habits with them. Over 60 million smokers or former smokers, all at risk for lung disease, are candidates for screening every three to five years. All adults are candidates for calcium screening, which can help direct therapeutic approaches. The demand for screening studies can be estimated at 45 million in the U.S., which translates to half of the U.S. population receiving a screening study once every three years.

This potential number of studies needs to be placed in the context of the 2001 estimate of 40 million CT studies performed in the U.S. There are now some 600 CT screening centers in the U.S. and that number can be expected to grow to 3000. Assuming that these 3000 centers are in operation because they can carry a full schedule-20 to 30 customers a day, 300 days a year-they could generate 22.5 million studies yearly.

There are 20,000 to 25,000 CT units now operating in the U.S. It is reasonable to expect that most CT operations will see demand for screening studies and that many of these the centers would want to avail themselves of this extra income. Assuming that each CT unit may do on average five screening studies per day, 17,000 CT machines could perform some 25.5 million studies per year. Adding the screening center volume to that of screening volume in other facilities with CT gives us a total of 48 million studies per year, which happens to make the potential supply coincide reasonably well with the potential demand.

Assuming $2 million as a dedicated center's startup cost, these 2400 or so centers will require $4.8 billion. Existing operations can provide screening services by the addition of approximately $100,000 of software and hardware to each unit, thus requiring a $1.7 billion investment, for a total startup cost of some $6.5 billion in, maybe, five years, or $1.3 billion a year. This is a fraction of the yearly expenditures in radiology and, barring a continuing disastrous stock market, not an unrealistic investment goal.

The funds needed for establishing and p aying for these services are not daunting in the context of healthcare expenditures. If there were 45 million studies performed a year, at $500 each these would generate $22.5 billion in revenue. In 2000, the healthcare bill was $1.3 trillion (this does not include food supplement, exercise, alternative medicine, and other health-related expenditures). Payments by private sources were $700 billion, and out-of-pocket payments were $320 billion ($100 billion came from other sources). It is hard to get reliable numbers, but the health and nutritional products industry may be $17 billion or $43 billion, according to two different sources, but these figures may be inflated. Expenditures at health clubs are also hard to come by, but two chains together claim some six million customers, maybe half of those members in the U.S. At $600 each a year, this would amount to some $1.8 billion for just these chains alone, not counting money spent on exercise clothing and equipment for the home. The system clearly has the elasticity to absorb investment and expenditures for screening.

WHOSE DOLLAR IS IT ANYWAY?

The cost-effectiveness of screening and the cost of follow-up of false-positive or inconsequential findings need to be considered separately. Payment for screening is an individual decision on how to spend discretionary dollars. One screening study every three years is less costly than membership in a health club over that same period. Cost-effectiveness applies to analysis that looks at how best to spend a fixed amount of money to benefit a particular population. The fact that it may cost $20,000 to find one operable tumor after screening 40,000 people may be valuable for health policy decision-making, but what this means at the individual level is that 39,999 people chose to spend $500 each and found nothing, and one spent $500 that probably saved his life (for the time being). These two perspectives are very different.

Self-paying raises the bothersome issue of multitiered care. I believe that it is detrimental for any society to have a large disparity in access to basic services and what are or are perceived as basic necessities. Not only is this detrimental to those who do not have, in the long term it is not good for those who do have. We depend on each other, and even if we considered living in barricaded housing developments a healthy choice, at some point the lives of the well-off have to intersect with the lives of the less-well-off. In principle, we should have equal access to healthcare, but beyond principle is reality. A recent study showed, maybe to only the investigator's surprise, that the poor have fewer choices than the rich. The history of medical care

in this country, however, shows that what is first available only to the affluent does become the norm for the less rich, and eventually the poor. If in the name of equality of access, the affluent were stopped from spending their money on the healthcare options they want, these options would never become available. As more centers open, prices come down, and more and more people can access this technology.

The cost of unnecessary follow-up does end up being covered to a large extent by the general fund pool. There is no simple answer to this issue. As a society, and under the prodding of both the government and learned societies, we have come to accept the expenditures for false-positive follow-ups to many other screening tests. All these result in large individual expenditures and morbidity. The lowest cost option is not to know, but this philosophy is fundamentally at odds with the nature of who we are and how we think. Controlling follow-up costs will depend on the quality of our physicians and the degree of trust they establish with their patients. It is ultimately a physician who determines what should be done next. Unfortunately, in today's environment this physician needs to look not just to learning, but also to the lawyer who may sue. I have more confidence in the medical establishment's ability to know what to do than in our legal establishment's willingness to accept this knowledge. These issues will slowly fade as the line between diagnosis and screening blurs.

Dr. Kaufman is CEO of AccuImage Diagnostics and president of International MRI AccreditationResources, both in South San Francisco, and a professor of physics emeritus at the University of California, San Francisco. He may be contacted at www.accuimage.com.