Getting ready for a return to more normal health care

We may not have realized it, but all of us have participated these last 12 months in one of the major health care experiments in recent times. It may reshape the practice of modern medicine, and could have big impacts on individual well-being and pocketbooks.

When the coronavirus pandemic raged in 2020, the U.S. medical system at times all but shut down, save for emergency treatment of those infected with Covid-19. Patients and doctors, hospitals, and labs canceled or postponed untold numbers of tests and procedures. This situation has gone up and down, especially as different parts of the country have become viral hot spots.

Researchers only now are piecing together the severity and duration of the medical system’s stoppage. But we are likely to get an unprecedented look from 2020 about the trillions of dollars we spend as a nation each year on health care. How many of these dollars are necessary? And how many are wasteful and driven by the medical establishment’s pursuit of profits?

If you feel bad or experience certain symptoms, common sense says to get in touch with your doctor and seek medical care — ASAP. But as the pandemic quells and greater normalcy returns, patients may need to be as skeptical as ever about their medical care, participating as fuller partners in their treatment, researching carefully, and asking loads of questions about tests and procedures ordered for them. This month’s newsletter: why and how.

The New York Times just carried a sobering story, quoting cancer specialists who say they are treating a wave of advanced cases in which patients might have benefited from earlier care had fear of Covid-19 infection not kept them away from doctors’ offices and hospitals.

Dr. Lucio N. Gordan, the president of the Florida Cancer Specialists & Research Institute, one of the nation’s largest independent oncology groups, told the newspaper: “There’s no question in practice that we are seeing patients with more advanced breast cancer and colorectal cancer.”

He and other specialists emphasized, however, that they are only beginning to compile the comprehensive data to support their anecdote-based concerns about postponed cancer screening and treatment. Worries about it have grown for months. This includes a published viewpoint in June 2020 by a respected clinician who estimated — he said conservatively — that the pandemic would be blamed for 10,000 excess deaths from breast and colon cancer in the next decade, with many of the fatal cases showing up in the next year or two.

Separating ‘signal’ from ‘noise’

That would be grim news, if true. But Dr. Scott Ramsey, a co-director of the Hutchinson Institute for Cancer Outcomes Research in Seattle, had a different take on the pandemic’s broader health care effects, as the New York Times reported in a separate article. He took note of the explosion of costly, invasive, and unnecessary medicine that patients in this country long have endured and told the newspaper:

“If we can separate signal from noise, maybe we can learn there are a lot of things we don’t need to do. Maybe patients will do better.”

It may be complicated to sort out the pandemic’s various effects on U.S. health care, partly because we access the system in varied ways — including with emergency, urgent, and routine care, preventative programs, elective procedures, and chronic condition treatment.

Patients prioritize their care, even in the best of times, depending on an array of factors. During the pandemic, fear of infection alone may have kept us away in droves from doctors and hospitals. But as the crisis deepened and wore on, its economic damage also may have slashed medical care because patients just could not afford it. Tens of millions of Americans lost employer-provided health coverage when laid off in 2020’s economic crash. Patients also may have struggled to get to appointments when public transportation closed, or, later, eliminated routes and slashed service hours.

Numerous studies throughout the last year, many based on opinion surveys, have documented how and why patients curtailed their medical care, reporting, too, how they said they also think their health suffered.

Finding a faster resumption of care

At the same time, research by the independent, nonprofit RAND Corporation raises interesting issues about heightened concerns about cancer screening, specifically, and why patients may need to be wary of doctors’ dire and even self-serving comments about pandemic-related delays in care. As the investigators reported:

“Screenings for breast cancer and colon cancer dropped dramatically during the early months of the coronavirus pandemic, but use of the procedures returned to near-normal levels by the end of July 2020, according to a new study. Analyzing insurance claims from more than 6 million Americans with private health coverage, researchers found that mammography rates among women aged 45 to 64 declined by 96% during March and April 2020 as compared to January and February. Similarly, the weekly rate of colorectal cancer screenings among adults aged 45 to 64 and older declined by 95% during the period.

“By the end of July 2020, however, the rate of mammograms among women had rebounded and was slightly higher than it had been before the pandemic was declared. The rate of colonoscopies also rebounded, although it remained below pre-pandemic levels, and did not rebound enough to offset initial reductions in care. ‘These are the first findings to show that, despite real fears about the consequences of drop-off in cancer screens, health facilities figured out how to pick this back up after the initial pandemic restrictions,’ said Ryan McBain, the study’s lead author …”

For patients, experience and rigorous research agree: Do not risk your health by ignoring important warning signs from your body and mind. If you experience symptoms linked with risky health or mental health conditions, you should get in touch with your doctor as soon as possible. Here are some checklists that will help.

Cancer

The American Cancer Society says patients should seek medical care quickly if experiencing these symptoms:

 Fatigue or extreme tiredness that doesn’t get better with rest.  Weight loss or gain of 10 pounds+ for no known reason  Eating problems such as not feeling hungry, trouble swallowing, belly pain, or nausea and vomiting  Swelling or lumps anywhere in the body Thickening or lump in the breast or other parts  Pain, especially new or with no known reason, that doesn’t go away or worsens  Skin changes such as a lump that bleeds or turns scaly, a new mole or a change in a mole, a sore that does not heal, or a yellowish color to skin or eyes (jaundice). Persistent cough or hoarseness Unusual bleeding or bruising for no known reason  Change in bowel habits, such as constipation or diarrhea, that doesn’t go away or a change in how your stools look  Bladder changes such as pain when urinating, blood in the urine or needing to go more or less often  Fever or nights sweats  Headaches, vision, or hearing problems  Mouth changes such as sores, bleeding, pain, or numbness

Circulatory

The American Heart Association says these symptoms should be dealt with urgently:

Heart attacks

Discomfort in the center of the chest that lasts more than a few minutes or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. Pain or discomfort in one or both arms, the back, neck, jaw, or stomach.  Shortness of breath, with or without chest discomfort  Breaking out in a cold sweat, nausea, or lightheadedness.

Stroke

Think of the acronym FAST: Facial drooping, Arm weakness, Speech difficulties and Time Face drooping or one side of face numb. Can the person smile? Is one arm weak, or numb? Ask the person to raise both arms. Does one arm drift downward?  Is the person’s speech slurred, are they unable to speak, or are they hard to understand? Ask the person to repeat a simple sentence, like “The sky is blue.” Is it repeated correctly?  If the person shows any of these symptoms, even if they go away, call 911 and get them to the hospital immediately. Time is brain.

Mental health

The National Alliance on Mental Health offers high cautions about these signs:

 Excessive worrying or fear Feeling excessively sad or low.  Confused thinking or problems concentrating and learning  Extreme mood changes, including uncontrollable “highs” or feelings of euphoria.  Prolonged or strong feelings of irritability or anger.  Avoiding friends and social activities. Difficulties understanding or relating to others Changes in sleeping habits or feeling tired and low energy.  Changes in eating habits, including increased hunger or lack of appetite. Changes in sex drive.  Difficulty perceiving reality (delusions or hallucinations).  Inability to perceive changes in one’s own feelings, behavior, or personality (”lack of insight” or anosognosia) Overuse of alcohol or drugs.  Multiple physical ailments without obvious causes (headaches, stomach aches, vague and ongoing “aches and pains”)  Thinking about suicide.  Inability to carry out daily activities or handle daily problems and stress.  An intense fear of weight gain or concern with appearance

Optimists see opportunities for needed change, even in the calamitous circumstances caused by the coronavirus pandemic that has killed almost 550,000 Americans and infected more than 30 million of us as of late March 2020.

Deferred care, for example, could lead patients to ask important questions that could change the practice of medicine and their own health, as the seasoned New York Times columnist Jane Brody posited in a recent column. She quoted Dr. William H. Shrank of Humana, a national health insurance company, and lead author of a report on waste in the current health care system:

“The pandemic has fostered ‘an opportunity for patients to take on a more active role in their care,’ Dr. Shrank said … Covid-based limitations gave prospective patients a chance to consider what procedures they really needed. Most elective surgeries were put on hold when hospitals and medical personnel were overwhelmed with the challenges of caring for a tsunami of patients infected with a deadly virus.

“Dr. Shrank suggested that people ask themselves, ‘How did you do without the procedure?’ Maybe you didn’t really need it, at least not now. Maybe instead of costly surgery for a bad back or bum knee, physical therapy, home exercises, or self-administered topical remedies could provide enough relief to permit desired activities. Does every ache and pain require a doctor visit?”

Brody also wrote this of herself: “Short of a catastrophic sign like crushing chest pain or unexplained bleeding, my approach is to wait a week or two to see if a new symptom resolves without medical intervention. I awoke one January morning with pain in my right wrist and forearm so intense I couldn’t brush my teeth. Perhaps I did too much crocheting or slept on it wrong. Ice didn’t help, but I applied an anti-inflammatory ointment, took two naproxen, wrapped my wrist in a brace from the local pharmacy and refrained from crocheting for two days, by which time the pain had resolved.

“When professional health care is needed, new approaches have become more acceptable during the pandemic, Dr. Shrank said. Emergency room visits and hospital admissions declined precipitously (though not always wisely by people with symptoms of a heart attack). Noting that many patients can be treated effectively at home by a visiting nurse, Dr. Shrank said, ‘No one wants to go to the hospital or a rehab facility if there’s a good alternative.’”

Problems spike when doctors overdo it

Over testing, over diagnosis, misdiagnosis, and over treatment plagued U.S. medicine in pre-pandemic times. It’s a topic worthy of a whole newsletter but know this: When it comes to medical screenings and tests, more isn’t always better. Early detection may not be all that helpful with some conditions and diseases, contrary to popular belief. And it’s, well, malarkey that doctors practice defensive medicine against medical malpractice lawsuits  by ordering excessive tests or procedures, just in case.

As health officials try to contain medical services’ soaring costs, they have zeroed in on an important gateway: over-screening, over-diagnosing, misdiagnosing, and over-treating that add $200 billion in unnecessary expenses to our care, with over-treatment costing 30,000 lives a year of older (Medicare) patients alone.

It isn’t taking patients’ temperatures or checking their blood pressure or getting them one or two tests that reformers assail. It is the cascade of costly, invasive, painful, and unneeded tests and procedures that follow. Every medical intervention carries with it an element of risk — indeed, some experts estimated that medical errors ranked as the No. 3 killer of Americans, claiming 250,000 lives annually in pre-pandemic times. It makes no sense to play the odds with your well-being by loading up your exposure in the health system.

Look at your own bills, too, and see how a routine, relatively inexpensive doctor visit can blow up with added testing costs. These might include tests for cholesterol (costing as much as $1,000), Vitamin D deficiency ($50 or so), diabetes (blood sugar $20), breast (mammograms, often covered by insurance but $20 to $60), or prostate cancer (PSA test $40).

Patients can find helpful, credible resources

Unnecessary and low-value tests abound so much that reformers have launched countermeasures. These include the Choosing Wisely campaign started after a 2012 report by the Institute of Medicine estimated that $750 billion — about 30% of all health spending in 2009 — was wasted on unnecessary services and other issues, such as excessive administrative costs and fraud.

Choosing Wisely, which now has a convenient app, asks clinicians themselves what tests and procedures, if ordered, patients should have a “conversation” with doctors about. That’s because the initiative’s respected specialists in a range of fields want patients to get treatment, they say, that is: “Supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” The group has, for example, questioned excessive prostate and breast cancer screening in older patients and doctors’ rush to subject patients with low back pain to complex and costly imaging studies.

The federal government also assembles a blue-chip panel — the U.S. Preventive Services Task Force — to review careful research, consult with experts, and make “evidence-based recommendations” to the public in understandable ways about “clinical preventive services such as screenings, counseling services, and preventive medications.”

The task force and Choosing Wisely both may get maximum public attention when they weigh in on much disputed topics like mammograms or prostate screens. But they both provide deep and accessible resources for patients wanting comprehensible discussions of tests and procedures doctors may order.

So, when you feel comfortable enough to resume the former pace of your pre-pandemic medical appointments, do some research and ask questions of your doctor or her staff, and you may better protect your health and your pocketbook.

Doctors owe you explanations 

Remember: Your doctor must provide you the fundamental right to informed consent. This means you must be told clearly and fully all the important facts you need to make an intelligent decision about what treatments to have, where to get them, and from whom.

On your return to more regular medical appointments, if you and your health have not changed significantly during the difficult pandemic times, you should ask lots of questions if your doctor suddenly decides you need a battery of new tests or a raft of repeat or unfamiliar procedures. Why? You should inquire, just as you would when you take the vehicle, which you have mostly kept parked in the garage and added only a few miles on, to a dealer-mechanic who wants to run the budget-busting “works” on your favorite ride.

By the way, just as many Americans saw their transportation costs plummet during the pandemic, the country recorded another fiscal rarity: The country in 2020 “bent the curve,” seeing the first year in at
least six decades in which America’s health care spending went down. It cratered early in the pandemic and recovered — some — in subsequent months. But not close to previous norms. As the Peterson-Kaiser Family Foundation Health System Tracker reported:

“[O]verall health spending appears to have dropped slightly in 2020 …  As of December 2020, health-services spending was down about 2.7% (seasonally adjusted annual rates) and it remained suppressed in January 2021. When adding in spending on prescription drugs, total health spending was down by just about 1.5% as of December 2020 compared to the same time in 2019. The U.S. GDP fell by 3.5% by the end of 2020, meaning that, although health spending dropped, it likely represented a larger share of the economy than in past years.”

The pandemic itself, of course, inflicted staggering economic damage, estimated by respected economists at mid-2020 at $16 trillion. The U.S. health system took a huge share of the fiscal hit, with uneven and disparate harms. Big academic medical centers and hospitals, including the wealthiest institutions and health systems, weathered the pandemic’s economic shocks far better, say, than their small, poor, and rural counterparts. Facilities serving communities of color struggled even more. Pediatricians, primary care practices, and dentists were slammed when public health restrictions slashed business, especially in comparison with, say, surgeons and elite specialists of various types, who saw their patient traffic rebuild and relatively quickly.

What are our health priorities?

Brody and others have pointed out that recent experiences with the coronavirus may compel patients and politicians to reconsider the country’s health priorities, especially when doctors who provide so many patients with valuable but general care can’t make ends meet and quit or become minions in groups owned and run by investors with max profits in mind.

Will health programs also recognize that prevention can be much cheaper than treatment? Will private and government insurers alter their policies and cover or pay more toward care now excluded for services by the likes of dietitians, physical therapists, and counselors? Would it be wiser to spend a little more on nutrition education, meal plans, exercise programs, and stress counseling, and much less on pricey procedures like electrocardiograms, angiograms, and treadmill tests? Could we spend a little more to crack down further on smoking and vaping, rather than forking over a lot more for lung-cancer chest X-rays or low-dose computed tomography?

Here’s hoping, of course, that you find a happy medium — that you take steps yourself, with your loved ones, and with your doctor for safe, effective, and affordable health care, especially so you and yours stay healthy throughout 2021 and beyond!