By Rochelle Sharpe
Can the government change the way that doctors care for their patients?
That’s one of the key questions reporters can try to answer as they cover the Obama administration’s efforts to promote comparative effectiveness research. The research, designed to determine the most effective ways to treat disease, could fill gaping holes in our medical knowledge.
The Health Policy law created an agency to oversee this work, the Patient-Centered Outcomes Research Institute, which recently released a draft of its initial priorities. The institute is sure to generate its share of controversy, given that conservatives fear its recommendations could lead to rationing medical care.
Reporters can go well beyond covering the institute’s day-to-day activities and explore the broader issues that the agency will be forced to confront for years to come.
I wrote such a story last fall for The Center for Public Integrity, which examined how much money is spent on unnecessary cancer screenings. I discovered that about 40 percent of Medicare spending on common preventive screenings is regarded as medically unnecessary by the U.S. Preventive Services Task Force. That amounted to about $2 billion spent on unnecessary tests over a six-year period.
The task force, an independent panel of medical experts, has a series of screening guidelines that are considered the gold standard for medical care. The panel is constantly re-examining its recommendations, and updating them when new information becomes available. But its advice has generated controversy, especially the recommendations that women in their 40s did not need mammograms routinely. When the task force first announced the suggestion in 1997, its members – some of the nation’s leading scientists – were accused of condemning American women to death. As I reported my story, many people completely dismissed anything the task force had to say, pointing to this controversial breast cancer recommendation.
So much for evidence-based guidelines. If the evidence doesn’t agree with what people feel, these recommendations can be an incredibly hard sell. But the debates make for compelling – and important – public health stories.
I began my story about a year ago, when the Center for Public Integrity asked me if I’d like to write an article for its ongoing series about unnecessary Medicare spending. The Center and The Wall Street Journal had banded together to get data from CMS, giving both organizations an opportunity to explore Medicare spending like never before.
I started the project by interviewing academics and other public health experts, asking what they thought Medicare was spending money on that was not medically necessary. While I considered a wide variety of possible angles, I was intrigued by preventive screenings. H. Gilbert Welch, a Dartmouth medical school professor, had just come out with his fascinating book, “Overdiagnosed: Making People Sick in Pursuit of Health.” Welch believes that overdiagnosis, the process of detecting medical abnormalities that will never harm patients’ health, is “the biggest problem posed by modern medicine.” (Here’s a New York Times op-ed by Welch.)
I discovered the U.S. Preventive Services Task Force had recently started recommending upper age limits on some screening tests – in part, because some cancers grow too slowly to actually harm an elderly person. There’s no point in screening – or treating – a 90-year-old for a slow-growing cancer, experts say, because that 90-year-old can’t live long enough to be harmed by the malignancy.
Welch wasn’t the only doctor talking about this issue. Lots of doctors were concerned – not just because of money wasted, but because people were being harmed by the tests. Some patients wound up suffering side effects from screenings – or more invasive follow-up tests. There also were unforeseen consequences. One elderly woman, who dutifully walked through a snowstorm to get an annual mammogram she didn’t need, wound up slipping on the ice and breaking her hip.
My colleague, Elizabeth Lucas, began running all kinds of computer analyses of the Medicare data. We found an extraordinary number of people were getting preventive cancer screenings well beyond the ages recommended by the task force. We even found dozens of 98-year-olds getting mammograms.
I not only looked at why so many doctors and patients were ignoring the task force’s recommendations, but also at why Medicare began paying for all these tests in the first place. Not surprisingly, I discovered all kinds of political wrangling and financial conflicts of interests.
So, how can you delve into this important topic?
First, for background, I encourage you to read Welch’s book. Also, I always set up a Google Alert, when I’m embarking on a new project. I made an alert for “medical screening test” and every day, received a number of interesting articles that proved helpful in the course of my reporting.
There are some terrific sources willing to talk about screening.
Welch and his colleagues at Dartmouth were very generous with their time. Also, members of the U.S. Preventive Task Force are quite accessible. I reached them, after speaking to the Agency for Healthcare Research and Quality, which arranges press for task force members.
The American Cancer Society is also a great resource. Otis Brawley, M.D., the medical director, is unbelievably outspoken and quotable. He’s also the author of a provocative new book: “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.” (As the keynote speaker at Health Journalism 2012 in Atlanta, Brawley spoke extensively about screenings.)
His colleague, Len Lichtenfeld, M.D., is also quite helpful. He also writes a terrific blog, which is a great source of potential story ideas.
Also, you may want to read or contact Rosemary Gibson, the co-author of “The Treatment Trap.” Gibson has an interesting webpage. She also helps write the “Less is More” series published in the Archives of Internal Medicine.
Topics to look at?
You could easily focus on PSA testing, which is very much in the news. In October 2011, the U.S. Preventive Services Task Force proposed downgrading its prostate screening recommendation, so no men would be advised to get routine PSA blood tests. (A final recommendation hadn’t been announced at this writing, and opponents were working hard to get it rejected.) In January, New Jersey Gov. Chris Christie signed legislation that asks Congress to reject the recommendation.
You could also look at the buses sponsored by Project Zero, which come to many towns around the country offering free screenings. Brawley, of the American Cancer Society, is concerned that people are getting screenings, but no counseling. Is that really true? Is counseling changing now that the task force is questioning the need for the tests?
Talk to people who go for testing to see if they received any counseling about the benefits and harms of such screenings.
For cervical cancer, you might want to look at how often women are getting Pap smears and HPV tests from their OB-GYNS. If women get negative results on both tests, they no longer need to get annual screenings. But is that happening? If not, ask OB-GYNs why they are ignoring the new screening methods and guidelines.
For stories about breast cancer, you may want to look at the use of digital mammograms in your area. Check out Joe Eaton’s story about digital mammography on the Center for Public Integrity website to see what the most important issues are.
And of course, the new Patient-Centered Outcomes Research Institute will provide fodder for all kinds of stories. What kinds of research will become the institute’s top priorities? And always keep in mind the bottom line; will the institute’s research, no matter what it shows, actually influence the way doctors practice medicine?
Rochelle Sharpe is a freelance writer in Brookline, Mass. She’s worked as a staff writer for The Wall Street Journal, Business Week, and USA Today, and is a Pulitzer Prize winner.
