Monday, December 10, 2012

Shared Decision Making, Screening Mammograms and Quality Care

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals & Managing Partner at Quo Magis Partners
  Issues in medicine typically evade grouping into “necessary” versus “unnecessary” or “good” or “bad” categories. Such is the case with the topic of screening mammography, perhaps, when viewed from the perspective of a patient or family member trying to make the most of a shrinking dollar while maximizing their health as they get older. For example, few would have argued that early diagnosis and treatment improves outcomes in most cancers.

The federal government, in fact, has endorsed screening mammograms in its 5 Star program, by paying Medicare Advantage plans explicitly for maximizing the percentage of female members between 40 and 69 who receive them every 2 years. Recently, a study in Lancet was published that concluded that for every life saved by mammography screening, 3 women will be “over-diagnosed” and ultimately treated for a cancer that may never have caused the trouble for a given person. The article suggests that screening “reduces breast cancer mortality but that some overdiagnosis occurs.”

In his book, “Overdiagnosed: Making People Sick in the Pursuit of Health”, Dr. H. Gilbert Welch, refers to some cancers as “incidentalomas” which are discovered as part of the screening we can now do enabled with-ever-more-sensitive technologies.

While I am not going to take a position on this topic, the point that I want to make is that it is confusing, at best, to the average patient. Certainly, what we “know” as indisputable fact today will be contradicted or clarified at some point in the future.

The best thing that can be done, then, for the average patient is to provide supportive guidance that stops short of being dogmatic about the use of such tests. While the quality indicators that are now driving Medicare Advantage Star ratings don’t take such nuances into account and carry real financial consequences for the plans if the member does NOT have the mammogram, the clinical and personal realities for a patient are shaded with elements that are not population-based, but very individualized. The things that motivate or demotivate a patient to receive that mammogram: fear of pain of the test or results that come from it, personal time and money, perceptions about the benefit versus the risk, and a variety of other factors. These are the real reasons a person will decide to have or not have a mammogram. And the quality question---may remain open for debate.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61216-1/fulltext

Terri is the founder of Cambria Health Advisory Professionals and a Managing Partner at Quo Magis Partners. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders. a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to IMS Health in late 2007. She has both a BS and a PharmD in Pharmacy and an MBA.