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Health reform skepticism, Part I

To the list of reasons Congress may find it difficult to rein in health-care costs, add "diagnostic creep."

Step One: Society medicalizes imperfections that formerly were either not defined as disease or thought to be too minor and/or too intractable for treatment. Rambunctiousness becomes attention deficit disorder; impotence becomes erectile dysfunction; snoring becomes a symptom of sleep apnea.

Step Two: Scientists discover treatments; government approves them; companies market them; physicians prescribe them; patients demand them.

Step Three: Disease definitions expand to encompass more marginal cases and treatments and testing expand to deal with more nuanced symptoms. Ritalin gives way to time-released stimulants; Viagra gives way to Cialis; sleep apnea comes in three varieties, mild, moderate and severe, identified through millions of dollars worth of high-tech sleep studies.

NPR's Alix Spiegel recently broadcast a fascinating piece about the campaign by Merck, the pharmaceutical giant, to expand use of its bone-strengthening drug Fosamax. The company's effort involved urging doctors to treat patients not only for osteoporosis but also for a milder form of bone loss known as osteopenia, which is common among middle-aged women. Encouraged by Merck, doctors began to think of it not as a natural aspect of aging but as a possible precursor to osteoporosis and fractures.

Merck also helped doctors get bone-scan machines in their offices so that they could test women for osteoporosis and osteopenia. And the company lobbied Congress to get Medicare to reimburse for the tests. Alerted by their friends, women themselves began asking for the tests and the pills. Result: Medicare claims for screening exams rose from 77,000 in 1994 to more than 1.5 million in 1999, according to Spiegel's report, and Fosamax prescriptions soared. By November 2007, Fosamax was one of the 100 most frequently dispensed drugs in the U.S., with annual sales of about $1.7 billion. (A generic version became available in 2008, so the national Fosamax bill is now likely to decline.)

Diagnostic creep sounds bad, but it obviously can be very good. Many children (and adults) have been helped by increased awareness of ADD and other previously unrecognized psychiatric conditions; drugs can indeed resolve their symptoms. Lord knows Viagra and its imitators have improved many lives. People who don't snore get better sleep; they're at diminished risk for conditions such as high blood pressure; they produce more at work; they are more alert behind the wheel. As Spiegel's balanced piece notes, Merck claims Fosamax helped many people prevent bone loss that could have led to even costlier problems. Who am I, or anyone else, for that matter, to draw the line between mere osteopenia and truly dangerous osteoporosis?

But that's just the point. Health-care cost containment is all about line drawing, about separating the problems that are dangerous enough to warrant coverage from those that aren't. Americans have become accustomed to the opposite of line drawing. In large part because someone else -- insurance -- picks up a lot of the tab, they have been habituated to consuming more and more life-improving treatments. Indeed, they've come to feel entitled to do so.

The health-care legislation being negotiated proposes measures to deal with spiraling costs -- including an excise tax on "Cadillac insurance plans" and a government panel to define what works best medically. I suppose those will have an impact. But to the extent they do, it can only be by pushing back against the public's sense of entitlement. Comparative-effectiveness studies can inform the discussion -- up to a point. We've already seen the blowback against one that suggested many mammograms are unnecessary or counterproductive. Is the government going to stop covering bone-density tests, much less tell women with osteopenia that insurance can't cover their Fosamax? I'll believe it when I see it.

By Charles Lane  | January 5, 2010; 1:37 PM ET
Categories:  Lane  | Tags:  Charles Lane  
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I think you're confusing problems with solutions. Your "diagnostic creep" is a symptom of today's for-profit medicine. Pharmaceutical companies are marketing disorders in order to market the "cure". You are expressing skepticism with health care reform because of a flaw with the health care status quo? Strange. Maybe you should take a pill for that...

Posted by: bidalah | January 5, 2010 3:32 PM | Report abuse

Basically it comes down to one question: Who would you rather have making the decisions on what can and can't be treated; the insurance companies who aren't at all held accountable, or the government, which at least in some respects can be held accountable. (Elections, media scrutiny, etc.)
And as you said, a lot that we pay for now can and does greatly reduce costs later.

Posted by: PeterPamZ | January 5, 2010 3:41 PM | Report abuse

Thanks for an interesting article. The probllem goes even further. To send a kid to camp, you need a doctor's ok. To excercise in a gym, you need a doctor's ok. To do many activities of daily living, you must have the approval of a young guy perhaps barely out of med school--a person who really doesn't care, but signs the paper giving permission. Our nation is ridiculously medicalized and the type of "medicine" is patriarchal. Many of the jobs of a physician could be done by other people such as midwives, chiropractors, etc. but they are not always permitted to do the jobs they do well because of our society. Medicine costs because it is designed to cost a great deal. We need changes.

Posted by: drzimmern1 | January 5, 2010 3:50 PM | Report abuse

Thanks for an interesting article. The probllem goes even further. To send a kid to camp, you need a doctor's ok. To excercise in a gym, you need a doctor's ok. To do many activities of daily living, you must have the approval of a young guy perhaps barely out of med school--a person who really doesn't care, but signs the paper giving permission. Our nation is ridiculously medicalized and the type of "medicine" is patriarchal. Many of the jobs of a physician could be done by other people such as midwives, chiropractors, etc. but they are not always permitted to do the jobs they do well because of our society. Medicine costs because it is designed to cost a great deal. We need changes.

Posted by: drzimmern1 | January 5, 2010 3:51 PM | Report abuse

Another way the drug companies keep costs rising is to claim a new use for a drug about to have its patent expire. This way, it remains under the control of the company, and it can't be made generically.

Posted by: jckdoors | January 5, 2010 4:20 PM | Report abuse

"Now that the House and Senate have both passed separate health care reform bills, the legislative process shifts to ironing out the differences. This typically involves having a formal conference committee containing members of both the House and the Senate. The goal is to reconcile the two bills, creating a final bill that both chambers will vote on. In a surprise turn, according to Jonathan Cohn of the New Republic, Democrats intend to employ an obscure tactic, informally known as "ping-pong," to shut Republicans out of the final negotiations and speed the bills toward completion. In "ping-pong" the legislation is bounced back and forth between the House and the Senate, controlled by just the Democratic leadership in each chamber and the White House, until a final agreement can be reached". We can only hope they just "ping-pong" their way out of office

Posted by: atthun | January 5, 2010 4:24 PM | Report abuse

comparative research can tell us 'hey, this new drug works, but... It doesn't work any better than the one that is no longer under patent protection!'

That can save us boatloads of money, as the corrupt drug makers currently hide all data from the public's eye. That way, markets don't work.

Remember that assumption about 'perfect information' to have a functioning market. Get ready for it, until the R's win and stack the board with Rx exec's. Then, we'll be back to square one again.

Government doesn't work, when it's run by people who don't want it too. But, it can be pretty good when adults are in charge.

Posted by: rat-raceparent | January 5, 2010 4:31 PM | Report abuse

Uh oh, Lane's pontificating out his kiester again. Yo Ezra, come get this fool!

Posted by: mrmoogie | January 5, 2010 4:39 PM | Report abuse

Actually I believe that Fosamax is now becoming "obsolescent" in favor of a new drug that only has to be taken once a month instead of once a week. What a boon!(doggle). And how much of all that R&D investment budget that we are supposed to be impressed by was a) R&D to develop this tremendous timesaving drug, and b) further research in marketing etc etc to launch the great "advance" in medicine.

Disclaimer: I was prescribed Fosamax 7 or 8 yrs ago. On the basis that the GYN asked me if I had had a bone fracture recently. Well, yes, I naively answered. Start taking this, he prescribed. What he never bothered to learn further was that actually I broke my wrist doing a nose stand on my mountain bike.

What a joke -- but not a very funny one. (No, I don't/didn't take it)

Posted by: icyone | January 5, 2010 5:13 PM | Report abuse

Nancy and Harry will try to keep a pillow and a blanket over their "reconciliation" talks. That says it all, America. That says it all.

Posted by: hearmenowbml | January 5, 2010 5:17 PM | Report abuse

A rational response to spiraling health care costs requires (gasp) rationing.

Demagogues on the issue demand silence on the rational course.

Posted by: edbyronadams | January 5, 2010 5:49 PM | Report abuse

Charles Lane may think he's found "diagnosis creep" in his story about Merck and Fosamax, but osteopenia IS a precursor to osteoporosis. I should know; I had osteopenia that then progressed to osteporosis. Next time get your facts right, Charles.

Posted by: posterchild90 | January 5, 2010 6:06 PM | Report abuse

The irony is that this repulsive, backroom dealing, partisan power grab really will be Obama's Waterloo.

Might as well get out the l'orange sauce for this lame duck. Cause nothing else that means anything to the liberals is going to get done...nothing at all. Of course that is a good thing. What liberals want has never been good for the country.

Hope this insurance, pharma, reform was earthshaking enough to use ALL of his political capital because it will be his legacy

The American people are NOT happy with the lies and underhanded, super shady process that the Democrats have engaged into keep the American people in the dark. Heck the majority of Americans are not happy with Obama and the democrats at all.

After this "bill" passes and America finds out just how ugly it really is..and they will...its not just bye bye democrats...its back to irrelevance for the so called progressive's.

Posted by: Straightline | January 5, 2010 10:37 PM | Report abuse

Obama Lied!!!!

Posted by: RongCapsFan | January 6, 2010 12:26 PM | Report abuse

Right, ADD is just rambunctiousness and sleep apnea is just snoring and middle-aged women should just suck it up and hope they don't get osteoperosis. Unless you're close to someone with such conditions or, you know, actually research them.

On the unrelated matter of pharma pushing overprescription of its drugs, that sounds like a really bad reason to sneer at strong health care reform.

Posted by: Cannoneo | January 6, 2010 1:01 PM | Report abuse

So, you must also believe that Lyme Disease and AIDS (both defined as diseases in the 80s) are simply "medicalized" conditions too minor or intractable to worry about?

I had Lyme disease in 1978, and it was treated just as you would have wished - as some sort of hypochondria easiest and cheapest simply to ignore.

Posted by: Itzajob | January 6, 2010 3:09 PM | Report abuse

As a physician who cares for patients daily, “diagnostic creep” and medicalization of “pseudo-disease” are real problems that can contribute to escalating health care costs. On the flip side, research has allowed us to further define people at high risk for disease where treatment is clearly warranted and thus become more confident in drawing those “lines in the sand”.

Osteopenia , or low bone mass as defined by a central DXA T-score of lower than -1.0 and better than -2.5 in appropriate individuals, clearly straddles that divide. By considering certain risk factors in those people with a diagnosis of osteopenia, we can more accurately identify those individuals who will benefit from drug therapy.

As many as 50% of patients with the diagnosis of osteopenia on a DXA study, have had a history of a low trauma or fragility fracture as an adult and clinically have osteoporosis. Other people with a diagnosis of osteopenia who have never fractured, may have additional clinical risk factors that also put them in a high risk category for fracture within the next 10 years. Both groups of patients should be prescribed FDA approved drugs for the treatment of osteoporosis based on current recommendations from the National Osteoporosis Foundation.

Other individuals with a diagnosis of osteopenia are not appropriate candidates for drug therapy. For example, pre-menopausal females without specific medical conditions, may be incorrectly labeled as having osteopenia based solely on a DXA test. There are also postmenopausal women with osteopenia who are at low risk for fracture in the near future. They should maximize their calcium and vitamin D intake, avoid cigarettes and excessive alcohol and engage in regular exercise. Monitoring their response with a bone density test several years later is an appropriate tool to determine if prescription drug therapy is warranted.

Bone density testing remains an important element in this decision tree and the United States Preventive Services Task Force recommends this for all women 65 years of age and older. Since osteoporosis can be a silent disease, a DXA test may be the first clue of osteoporosis. Despite concerns raised by Mr. Lane and those covered in the recent NPR broadcast, Merck was instrumental in increasing awareness of osteoporosis and ensuring that physicians and patients understood the potential value in bone density testing. Although the number of DXA studies submitted to Medicare has increased from 77,000 in 1994 to over 2.1 million in 2008, this still represents less than 13% of eligible Medicare beneficiaries. The increase is not reflective of overutilization of testing, but underscores both how far we have come and how far we need to go in our efforts to prevent this potentially devastating disease.

Posted by: ajlasterMD | January 6, 2010 8:36 PM | Report abuse

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