Wednesday, January 17, 2007
Paying the price for preventive care

Last week I had my heart checked out and this morning I talked about the exam on CNN.

Truth is, I feel pretty good, I try and stay healthy and I eat well. I don't take any medications, but I do worry about heart disease because of family history.

If you talk to a dozen different cardiologists, you will probably get a dozen different responses about what a healthy person should do about preventing heart disease. My cardiologist wanted to examine my heart through a series of blood tests and a very sophisticated test called a CT angiogram or CTA.

My blood is being tested for the usual suspects, cholesterol and fats, but also things like genetic profile and inflammatory markers. I will get those results in a couple of weeks. The CT angiogram, which was completely non-invasive except for an IV, took incredibly high quality pictures of my heart, as you can see. The test will detect any calcifications as well as narrowing in the blood vessels and abnormalities in the blood vessel wall.

My test was completely normal. Reassuring.

It is one of the best tests for identifying heart disease, but it's not cheap - a little more than $1,000. Unless you are having some problem like chest pain, insurance probably won't cover it.

Many doctors feel that sort of thinking by the insurance companies is preventing us from becoming a culture of prevention. What do you think? Is an ounce of prevention really worth a pound of cure?
The way this nation eats is "Culinary Suicide". We lead the world in the incidence of heart disease. Most of the time, the heart is ok, it's the coronary arteries that are occluded. The best non-invasive procedure to determine the health of your coronary arteries is a Nuclear Stress Test.
The majority of heart attacks can be avoided by taking one of these tests. Despite popular opinion, I believe people should start having this test by age 40 (especially women, as they are more prone to cardiac death than men).
No matter how good you might feel, if you have Coronary Artery Disease, you must be aware of it and act on it as early as possible.
If this were done, the number of heart attacks in this country would plumit and insurance companies would save millions of dollars.
Dr Gupta is confusing testing with prevention. You can get all the tests in the world, but if you keep your butt glued to the couch, you will not improve.
An ounce of prevention is worth a pound of cure. Prevent heart disease by exercising regularly and eating right. Walking and aerobics are free. Nutritious food costs about the same as sugary, greasy food. It has nothing to do with insurance companies.
Instead of encouraging prevention, Gupta might be promoting the perception that quick fixes - like tests and drugs - are the answer. As long as people think there's a quick fix to their health problems, health costs will remain high.
Yes, an ounce of prevention is worth more than a pound of cure nowadays. Just compare the cost of simple preventive procedures (e.g., blood tests) and lifestyle changes (e.g., altering diet, exercise, taking prescription medications early on) with the cost of various major surgical procedures to correct problems later on. In my case, the cost difference is not only substantial in terms of money but also in terms of absence of future complications. No future complications can mean future monetary savings as well as a better lifestyle in the future, and how much is that worth to a person?
If I was an insurance company I'd rather pay a $1,000 bill than a $50,000 bill - so why doesn't preventive coverage make any sense?

I do not suffer from high blood pressure or any other indicator of heart disease, but my family history would prompt me to have these tests run as I enter my late 40's - but I won't because insurance won't cover the cost - until it's too late.
Dr. Gupta,

Thank you for informing us of another type of exam that could be useful in preventing a catastrophic event. It is so unfortunate that insurance companies would rather pay for a very expensive heart procedure or other types of procedures that could be prevented if they would have authorized what the doctors request. Dr. Gupta, I have the following question and concern? I have been having flutterings, gurgling, and according to the doctor, they are called palpatations. I have had them off and on for approx. 4 to 5 years. I've been given the following exams to the locate the problem: Regular stress test, Cardio-Lite Stress test, Echograms (2), EkGs, and Event recorders (24 type and 30 day type). The first ECHO was done approx. 3 1/2 to 4 years ago with an outcome of OK. The second ECHO was done approx. 1 year ago with an initial diagnosis of OK, but after a followup regular scheduled visit a year later, the initial original diagnosis a year earlier was revised and I was told that now, the diagnosis was a condition called, MITRAL VALVE PROLAPSE. My questions are, why would it take so long (1 year) for an original diagnosis to be revised and updated from the same test a year earlier? Second question, is MITRAL VALVE PROLAPSE dangerous and has it been the cause of my symptoms for approx. 4 years? Sometimes, when the I get the symptoms, I feel a little weak, but I slowly recover. This is a scary experience. I've been told by my Cardio and his electrophysicist to just ignore the symptoms when there are occurances because I will be fine when they pass. Please let me know if it is safe to JUST IGNORE THE SYMPTOMS. Is there anything that can be done to prevent or eliminate these symptoms? Sometimes it feels like my heart will stop from the terrible sensations. We would really appreciate your guidance. Thank you and take care.
You are definitely confusing testing with preventing. Plus we need more prevention in the form of figuring out exactly what's causing so much disease - hmmmm could it be exposure to chemicals? Chemicals in the foods we eat, water we drink, air we breathe???
I'm a student in a physical therapy program in Wisconsin. As I learn more about the health care system and the costs of both preventative and reactive care- it is becoming obvious that preventative care is vital. It is easier, and more beneficial to catch a failing coronary artery before it causes coronary heart failure than on an autopsy table. I would rather pay $1,000 for a preventative scan than $40,000 for heart surgery after a heart attack.
In my case, if my medications were not covered by insurance, I couldn't afford them. I won't die without my medications, but I would end up in the ER on a weekly basis to get stabilized.

I would say prevention is definitely preferable over the alternative, although I wouldn't mind a cure for my chronic health condition either.

The earlier my condition is caught and the earlier you start on the proper medications and management techniques, the less amount of long term care necessary. Too bad standard policy is ignore most people with "odd" symptoms until their condition is so bad it is obvious what is wrong.
I think the issue is being confused. The big questions are: (1) Hooray, we have this big fancy good is it in actually predicting heart attacks or death from heart disease and how does it compare to tests we already know about, (2) Who do we screen....everybody over 40? 50? All men? People with symptoms? The easy questions are which tests are available. The harder question is which ones are actually helpful. It is easy to say that it costs less to do a $1000 test than pay for bypass surgery. But does the test actually prevent the need for surgery? How many false positives are there? How many false negatives? How many tests do you need to do to prevent one heart attack? These are not easy questions, and require well-funded studies.

I am a primary care doctor and my greatest concern is preventive medicine. That does not mean I think everyone should be screened for everything. As you know, that leads to a lot of unnecessary testing and follow-up, anxiety, and misdirection. Once a test has been shown to have significant predictive effects and can allow us doctors TO CHANGE OUTCOMES, it should by all means be covered by insurance. The fact that insurance companies sometimes do not cover tests such as colonoscopy is an atrocity. We have a test that has been shown to detect, treat, and help prevent cancer and there is no guarantee that everyone over 50 can have it done. I think we should focus our attentions as a society on finding and implementing coverage for tests that actually PREVENT.

Until this CT angiogram has been shown to be effective in this manner, I will continue to think of it as an experiment awaiting a function. We should encourage prevention, but we should not give doctors or anyone else blanket allowance to order tests just because they are available.
Rich need these tests
Most of the tests are expensive but the rich can afford it. Hopefully the middle class doing some manual work, playing and exercising with healthy-non greasy food does not need it. Remember you can still get it but initial stages of any sickness can be easier to treat, but dont worry with overdoing and getting worried - being less informed can be a gift here :-)
As a student studying public health and medicine, I do see that many patients are not being covered for screening tests and thus certain diseases like cancer are often not detected early enough. Surprisingly, this creates greater expenses in the long run. I believe that however, physicians may be ordering so many tests all of the time without a real reason and this leaves the insurance companies worried about authorizing even more tests. There should be studies that not only show the medical efficacy of these important tests but perhaps there should be a section in a peer reviewed journal article about the test's cost effectiveness.
Detection is not prevention nor preventive care. If you detect something you already have it. Prevention is pursuing an anti-inflammatory diet and exercise.

Thaddeus Gala DC
I definately agree with your opinion that high costs and our inability to pay is preventing us from becoming a culture of prevention. Especially as a foreigner living in the US, I know that I cannot take advantage of many of the potentially helpful test that are being developed today. I think this is something to think about for a country like the States, where the population is getting increasingly diverse.
ralph and sunil hit it right on the money when they say that testing isn't prevention, exercise and diet are.
I totally agree-my health insurance did not pay for my preventative mole removals-paid 2,000 bucks!!!! I have been a nurse for 10 years and I just did not like the look of the moles-dermatologist told me they were fine-but I had an inkling-4 out of the 8 came back pre-cancerous!!!!! Do insurance companies want to wait until you have melanoma to pay???? they should be thanking people like us for being on top of things-and it is unfortunate for others bc most people cant pay 2000 dollars to do preventative care, I am lucky in that respect, I could pay- it should be covered for ALL people to prevent something worse.I didnt realize the insurance companies had their MD degree
I own a small business with 3 employees and have a health plan through Anthem BC. I pay $9600 yearly for me and my spouse with a deductable of $3000 for each of us during a calendar year. For us to have a baseline colonoscopy or skin cancer screening we have to pay our deductable before Anthem insurance kicks in. I don't believe we are alone in that we put off having our baseline tests because of the cost, but at 51 & 53 years old, pray that the cost of insurance and the deductable don't increase too much more before we can afford the extra $6000 for these tests.I believe this happens frequently, yet I never hear about this issue in the news. Perhaps you can help spread the word regarding high insurance deductables along with the prohibitive costs.
I absolutely agree about the prevention being worth it. However, you will probably agree with me that if Americans would just change their lifestyles, quite a few health problems would go away!
Get off the scare bandwagon and look into natural supplements keep going to your doctor look at your tests, but I have taken action to prevent this and other disease by taking a full compliment of vitamines and supplents, almost NEVER eating fast food. I pack my lunch EVERY day and include in it an apple yougurt and a sandwich or two that I and have a total gym at home to exercise. Get off the scare tactics if your not on some kinda perscription drug don't be a dope and get on one chances are you DON'T need it everyday doctors are trying to brainwash us into thinking we have some as of unknown "condition" to get us to take drugs and make us believe we aren't healthy, use YOUR brain and think for YOURSELF.
I plan on becoming a doctor in the near future and my goal is to advice my patients with information regarding prevention of diseases. So yes its better to take preventive measures. I agree with my doctor's statement, "You are better off with what God gave you than what I can provide you with." I feel that many insurance companies are in it to make money than to actually help patients.
Yes doctor i,m tired of the insurance companies having the edge on ever turn of health insurance , like putting on deductiblies on everything plus they have and excuse why not to pay for tests that can save your life in the future why? Thank You doc for caring.
I belong to an HMO. About two weeks ago I chose to fill a debris can with wet leaves on a cold night in the rain. I had had a "small" heart attack in 1994, and my lipid panels as well as blood pressure are very good (below condition the readings suggested), however I experienced chest pains and an increased heart rate. I made it into the house and after awhile my heart rate was down and the angina disappeared (it never was very severe but it was painful). I sent my cardiologist a complete description of my symptoms, and the next day she said I should be concerned with my chest pains and not my heart rate. Since my experience my heart rate isn't always within the normal rate for me (51 to 63) which it was prior to my heart rate experience. I have recently called asking if there was any non-invasive tests I could use that would indicate the state (status) of my heart and arteries. Her answer was that the only thing available was a angiogram( I have had 3 of those as well as two very successful angioplasties), but that she didn't want to take the RISK of an angiogram until we see how I do in the future. That to me means wait until I either have a heart attack or start having significant angina's. Needless to say i was somewhat upset I was told to wait until I see what happens. I know there is a danger of a stroke or even a heart attack during an angiogram therefore I surmise she feels that's the case with me. She didn't offer me anything else, therefore I sit alone (I'm 78) waiting for "something" to happen. Not a good place to be even though I'm only 2 1/2 minutes away from a huge hospital with a wing devoted to the treatment and research of heart disease. At the moment I'm not sure if that's the proper method to follow or if she is "guarding the HMO's gate"!
ralph and sunil are making the same mistake that most of the primary care community makes. screening for heart disease and using CTA to detect asymptomatic plaque is a form of prevention. that is precisely why it is done, so one may be placed on appropriate medications and/pr be even more frequently screened. yes, ralph we already know we should diet and execise. it's really working well in this country
I have extreme high risk for heart disease. I have been fighting high cholestrol (the family curse) since the age of 30 (I am now 46), both parents have high blood pressure/hypertension, family history of heart disease. I lupus as well.

Is there research on the effect of autoimmunity has on the heart? Is there information on lupus and heart disease? I know that some autoimmune disorders are considered inflammatory diseases.
My experience as a student definitely supports the notions that insurance programs discourage preventative testing. Until I meet a $2,500 dollar deductible I have to pay for all of my doctors visits out of my own pocket. I keep my health insurance in case of serious injuries or illnesses, when $2,500 will be a drop in the bucket, but it is too expensive for me to afford better insurance that would pay for routine blood tests, or to pay for them myself. On the other hand this has forced me to keep better track of my health at home (weight, body fat, hematocrit, serum protein, BP, heartrate, temp, etc).

All in all, despite the costs, an ounce of prevention is worth a pound of cure. Especially since there are still many things we simply cannot cure.
Just a comment about Metastases.
Isn't Chemotherapy also meant to deal with Metastases ? Your discussion with Armstrong & co created the impression there has to be a separate treatment for Metastases in all cases of Cancer
sanjay, you're so brilliant, so nice, and so naive..if you lived in the real world you wouldn't even mention the words "insurance companies"..truly unbelievably, the medical field is nothing else, but big business in this country..millions of americans would tell you that "insurance companies" and the majority of doctors don't care if you live or die..of course prevention makes a lot of sense, but , just one tiny example, my insurance company wouldn't even pay for a consultation with a dietitian, before i come down with deadly diabetes (i was diagnosed with insulin resistance by one doctor, although another disagreed)..what's out there is a disaster, sick people are stressed out of their minds, trying to do their own research, fight with doctors and insurance companies (if they're lucky to have one)..sanjay, if you really do care about people join the fight for universal health care..that's our only hope..thanks
Marta, i am quite sure you are the one who is frighteningly naive. The universal health care plan that you crave would see to it that you would never get an appointment with a dietician. In fact, you probably wouldnt get much of the medical testing and procedures now available. You should go live in Canada for a year and then criticize the US health care system. Forget dieticians, I suffered with neck pain for two years before I could get an MRI, which showed that I needed surgery, but alas it was too late. I think Dr. Gupta is right on the money for raising the issue without stepping out of bounds.
I really wish insurance companies and HMOs would get on board with preventive tests and treatments. The financial expenditure for an HMO to provide treatment to a patient after a heart attack far ouweighs the lousy $1,000 for such a comprehensive test as the CTA. To rewrite an old adage, an ounce of prevention is worth a pound of health. Especially no that we have so many people living longer lives, why can't we as a nation encourage health insurers or HMOs to include preventive diagnostic testing in their health plans? I would gladly pay the few extra dollars per month for my health insurance if it included, say, an annual CTA exam among others (like maybe an annual CT Scan the might have helped prevent my recent stroke.) Isn't health mainly about preventing illness?? Is anyone paying attention ??????? Why do we watch our diets. to PREVENT illness. So if we have the technology to detect health concerns BEFORE they become serious, why the heck aren't our legislators working on a national health plan or working with healthcare insurers to make such testing available to the average citizen????

Once again, is anyone paying attention?????
I would pay the 1000 bucks just to know how my heart and arteries are doing. No doubt.

I just wish my insurance would agree with me on this. I have hereditary heart desease. I eat right and exercise daily, but my arteries are clogging just the same. It would be nice to have such a test done at least once a year.

I assume that the test is much cheaper than an actual bypass or anioplasty? (sp)

I guess what comforts me is that the insurance compay will end up "paying" for their ignorance. Of course I will also. Maybe they hope I won't make it to the actual surgery?

I hope we can change this and together spread the word of how important these preventive measures are.
We are a cardiology practice in South Florida, and we totally agree that the system is backwards. That's why we are starting an Executive Health Program, not merely for executives, but for those who wish to know they are healthy, or possibly not, before the symptoms arise. Unfortunately, they will have to pay until insurance companies take some responsibility. I for one would want to pay up front, as you did, just for the peace of mind. Not all people can afford to do that.
By the way, do you know any cardiologists that would like to join me in sunny Florida? I am so busy and having a hard time finding an associate. Send them my way, would you?
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