As goes college, so goes health care?

My oldest child is applying to college this year. He is an outstanding student and likely to be offered significant scholarships, so my wife and I are not concerned about him (and us) being able to afford the tuition to the college he ultimately chooses. Tuition and fees at U.S. colleges actually increased at a lower rate than general inflation from 2022-23, breaking a 20-year trend that saw tuition increases for private and out-of-state public schools far outpace concurrent rises in incomes and costs of living. As a result, college has become less and less affordable, particularly for students who end up relying mostly on loans and rack up gigantic debt loads even if they don't complete their degrees.

But college-educated adults earn a lot more money than those without college diplomas, so going to college still makes economic sense, right? Maybe not. A few months ago, a New York Times Magazine story by Paul Tough (whom I've quoted previously on my blog) discussed "the new economics of higher ed." He cited the work of three researchers at the Federal Reserve Bank of St. Louis who found that looking at wealth accumulation rather than income, college graduates born in the 1980s or later had little advantage over their peers who didn't gradate from (or even start) college, with Black and Latino college graduates worse off than White college graduates. Data on postgraduate degrees was even more bleak: there seemed to be no wealth advantage at all.

Millennials with college degrees are earning a good bit more than those without, but they aren’t accumulating any more wealth. How can that be? ... The likely culprit, [one researcher] said, was cost: the rising expense of college and the student debt that often goes along with it. Carrying debt obviously diminishes your net worth through simple subtraction, but it can also prevent you from taking important wealth-generating steps as a young adult, like buying a house or starting a small business. And even if you (or your parents) were able to pay your tuition without loans, the savings you used are gone when you graduate, and thus are no longer available to serve as a down payment on a starter home or the beginning of a nest egg for retirement.

Fueled by skyrocketing tuition costs, total student loan debt more than tripled from $500 billion in 2007 to $1.6 billion today, and in an even more stunning statistic, "among student borrowers who opened their loans between 2010 and 2019, more than half now owe more than what they originally borrowed."

It's possible that demographic trends will act to moderate tuition costs in the future; as the pool of students finishing high school shrinks, colleges may need to keep tuition increases low to compete financially. For the sake of my pocketbook (my high school senior son is the oldest of four children), I certainly hope so. But reading about higher education made me think about another sector where costs and fees have been rising exponentially while the return on investment is middling and the quality of the product remains opaque: health care.

Since 1980, the U.S. has spent more on health care as a percentage of its gross domestic product than any other country in the world; today, nearly 1 in 5 dollars generated by the American economy goes to the purchase of health care. Yet average life expectancy stopped rising in 2010 and plummeted during the first two years of the COVID-19 pandemic, far more than in comparable countries where the average resident lives 5-6 years longer than we do. Further, U.S. men now are expected to die 6 years earlier than women, the widest gender gap in nearly 30 years, according to a recent study in JAMA Internal Medicine. The biggest drivers of this gap were deaths from COVID-19 and drug overdoses, which medicine can prevent with highly effective interventions: vaccines, medications to treat opioid use disorder, and the opioid reversal agent naloxone.

It's not that patients aren't enthusiastic about prevention. We spend $35 billion per year on largely worthless over-the-counter dietary supplements. According to a recent analysis of data from the National Ambulatory Medicare Care Survey, the proportion of primary care visits "with a preventive focus" increased from 12.8% in 2001 to 24.6% in 2019. But the services doctors provide at those "wellness" visits - mammograms, PSA tests, colorectal cancer tests, and CT scans for lung cancer - generally don't help people live longer and often lead to unintended harms. While discrete medical services don't save lives, we know that having a relationship with a primary care physician does. Good luck getting in to see one, though, when the pay gap between primary care and subspecialists discourages medical students from becoming family physicians, and the percentage of health care dollars invested in primary care nosedived from 2013 to 2020.

Will the U.S. eventually reach a "breaking point" when, like college today, people realize that they are being fleeced by a self-perpetuating sick care system and demand greater value for their money? Such as sending more of the trillions of dollars spent on health care toward primary care? Some states are starting to recognize the wisdom of increasing primary care spending, but progress has been slow. Our country would do well to heed this advice that I've adapted from food writer Michael Pollan: Get real health care. Not too much. Mostly primary care.

Bariatric surgery and other AAP recommendations for children with obesity

A recent article in The New York Times Magazine profiled a 16 year-old girl with severe obesity who underwent bariatric surgery at a children’s hospital in Texas. In January 2023, the American Academy of Pediatrics (AAP) published a clinical practice guideline that suggested referring all children 13 years and older with a body mass index (BMI) greater than or equal to 120% of the 95th percentile for age and sex for bariatric surgery evaluations. Although only a tiny fraction of eligible U.S. adolescents undergo surgery, the number of procedures increased from fewer than 800 in 2016 to 1,349 in 2021. (In comparison, more than 200,000 adults had bariatric surgery in 2021.)

In an editorial in the October issue of American Family Physician, Dr. Kathryn McKenna and I analyzed the quality and quantity of evidence supporting the AAP guideline recommendations. Notably, few studies have evaluated short-term outcomes of the most commonly performed metabolic surgery procedures in adolescents, and long-term outcomes are unknown. Similarly, although semaglutide (Wegovy) was approved by the U.S. Food and Drug Administration in December 2022 for treating obesity in adolescents, we pointed out that “only 5 out of 27 randomized controlled trials [of pharmacotherapy] included results beyond six months.”

The desire of family physicians and pediatricians to make an impact on the obesity epidemic, which affects 22% of adolescents, is understandable. To date, the results of nonpharmacologic, nonsurgical weight interventions recommended by the U.S. Preventive Services Task Force have been mostly disappointing. A 2017 Cochrane review of 70 randomized, controlled trials concluded that diet, physical activity, and behavioral interventions in elementary school age children (age 6 to 11 years) have modest short-term effects on weight and BMI compared to no treatment or usual care. A more recent Cochrane review confirmed this finding but also found low-quality evidence that these interventions did not change BMI in children 13 years and older.

Could intensive weight management of children with obesity cause unintended harms such as increasing rates of disordered eating? This possibility hasn’t been well studied, but anecdotes suggest it is a real concern. A STAT News story about the AAP guideline interviewed an eating disorder specialist at Boston Children’s Hospital who “has seen weight fluctuations evolve into serious and possibly life-threatening eating disorders,” and the New York Times Magazine article related the story of another patient who developed life-threatening anorexia after she was referred to a weight management program by her pediatrician. Although the AAP guideline authors discussed several expert-recommended approaches to mitigate this risk (use nonstigmatizing language, eliminate blame, and focus on improving health status rather than weight or BMI), these approaches are implemented inconsistently in primary care practice, where adults with obesity often experience weight stigma and bias.

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This post first appeared on the AFP Community Blog.

Medical debt is a moral failure of our health care non-system

When I changed employers in 2022, I also changed the health insurance plan for my family from traditional coverage to the "consumer" option: a high-deductible plan with a health savings account option (HDHP/SO). This type of plan used to be called catastrophic coverage because except for certain preventive services, it doesn't cover any health care expenses incurred during the plan year until (in my case) the insured person(s) meets a deductible of over $4000 in claims. The plan makes sense for us because the lower premiums almost exactly offset the deductible over the course of a year, and we have more than enough cash to pay for care expenses less than that amount. But according to the Kaiser Family Foundation's Employer Health Benefits Survey, HDHP/SO type plans now cover 29% of all private sector employees with health insurance. Since 63% of workers are unable to pay a $500 emergency expense without borrowing, it's doubtful that all of the people covered by these plans have $4000 in easily accessible savings. So for them (and for tens of millions of uninsured Americans), an unexpected emergency room visit or hospitalization will likely lead to medical debt.

A recent article in the New England Journal of Medicine reviewed the history of medical debts in the U.S., which "since the 1980s ... have shifted from obligations negotiated by doctors, patients, and hospitals to assets bought and sold by people with no role in patient care." After the Emergency Medical Treatment and Active Labor Act (EMTALA) passed in 1986, requiring hospitals to provide emergency care to patients regardless of their insurance status or ability to pay, hospitals became more aggressive about referring patients with unpaid balances to debt collections, to such an extent that "by 1993, hospitals were the source of more business for debt-collection companies than any other industry."

A Commonwealth Fund survey of working age adults found that 32% had medical or dental debts that they were paying off over time. As one might expect, uninsured persons (41%) and persons who incomes of less than 200% of the federal poverty level (44%) were more likely to be in debt, but 30% of persons with employer-based insurance were also in debt. These debts caused substantial percentages to delay or avoid getting needed health care or prescription drugs (36%), cut back spending on food, heat, or rent (39%), and worry about how they were going to pay off the debt (78%). Rather than making payments to collection agencies or banks, two-thirds of people with medical debt were making payments directly to hospitals or care providers. Similarly, a study of pre-pandemic data from the 2018-19 Medical Expenditure Panel Survey found that 27 to 45 percent of adults younger than age 65 spent more than 10% of household after-tax income on out-of-pocket health care costs, were unable to pay medical bills without going into debt, or went without medical, dental, or prescription drug care because they could not afford it.

In the past, I would have said that having the national uninsured rate fall to a record low of just 7.7% during the first quarter of 2023 would be cause for celebration. But the majority of these gains, which resulted from the COVID-19 pandemic era prohibition of Medicaid disenrollment until the end of the public health emergency, are currently being undone, with many eligible persons having their health insurance terminated due to paperwork errors or misdirected mail notices rather than any change in their economic status. And as I've explained here, having health insurance is no guarantee of protection against medical debt.

Medical debt is a moral failure of our health care non-system. If the fire department comes to put out an accidental fire at my house, I will need to pay for the damage out of my home insurance policy, but I won't incur any fire department debt. If the police respond to a break-in at my office and eventually catch the burglar (or not), my employer won't incur any police department debt. The debt we owe our military veterans for protecting our country is arguably priceless, but you won't ever receive an itemized bill to pay your share in monthly installments of the cost of their domestic or overseas service. Medical debt will only cease being a problem when our country finally recognizes that health care for people younger than age 65 is a community and national responsibility, rather than an individual one.

Health journal editors and the Pope call for action on the climate crisis

Last month, two major documents – one by a coalition of more than 200 health journal editors, the other from the leader of the Roman Catholic Church – invoked science and faith to advocate for aggressive action to address the climate crisis. On October 25, an editorial published simultaneously in participating journals declared that “climate change and biodiversity loss are one indivisible crisis and must be tackled together to preserve health and avoid catastrophe.” As previous group editorials have outlined, climate change poses ongoing threats to human health by creating “shortages of land, shelter, food, and water,” particularly in poorer countries that generate far fewer greenhouse gas emissions per person than the United States. Further, the authors argued that the climate and nature crisis meets World Health Organization criteria to be designated a global health emergency.

Three weeks earlier, on October 4, Pope Francis issued an apostolic exhortation “to all people of good will on the climate crisis,” warning that “the world in which we live is collapsing and may be nearing the breaking point.” After refuting disinformation that human activities are not responsible for our warming planet, he declared that “the world … is not an object of exploitation, unbridled use and unlimited ambition.” Reviewing the limited progress in reducing emissions following past global climate conferences and looking ahead to the 28th United Nations Conference of the Parties (COP28) in Dubai at the end of November, Francis acknowledged that “the most effective solutions will not come from individual efforts alone, but above all from major political decisions on the national and international level.”

An International Energy Agency report released in September projected that worldwide demand for fossil fuels will peak before 2030 due to the accelerating transition to solar and wind energy. This movement creates a narrow path to achieve the international goals of net-zero emissions by 2050 and limiting global warming to 1.5 degrees Celsius (2.7 degrees Fahrenheit). Remaining below this temperature threshold reduces the risk of catastrophic climate events such as this summer’s Canadian wildfires, which not only burned more than 45 million acres (the country’s previous single-year record was 19 million), but released an estimated two billion tons of carbon dioxide into the atmosphere.

The U.S. health care industry remains one of the world’s largest climate culprits, producing one quarter of global health care emissions and 8.5 percent of all U.S. emissions in 2018. U.S. hospitals are half as efficient as European hospitals and cause air pollution that leads to an estimated 77,000 excess deaths annually. Overuse of single-use disposable plastic devices is an important part of the problem, a recent JAMA Viewpoint observed:

In addition to personal protective equipment (masks, protective gowns, and gloves), everyday items such as blood pressure cuffs, catheters, complex surgical instruments, and even bed linens, pillows, and patient gowns are laden with plastic and commonly discarded after a single patient encounter. … However, there is a dearth of evidence of benefit from most single-use devices—especially for infection prevention—and dependency on them increases supply chain vulnerabilities.

Aligning infection control guidelines with evidence and prioritizing reusables in medical device regulation could incentivize health care organizations to purchase more durable, reusable patient care products.

More broadly, overdiagnosis and unnecessary medical treatment not only waste money and energy and expose patients to harm, but also increase the carbon footprint of health care. The scientific committee of this year’s Preventing Overdiagnosis conference called on decision makers to embrace sustainable health care approaches and acknowledge that “our global medical culture has driven excessive diagnostic testing, overmedicalisation, and overtreatment across many conditions that may harm patients, exhaust health care resources, and harm the planet.”

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This post first appeared on the AFP Community Blog.

Task Force to revisit prostate cancer screening recommendations

The U.S. Preventive Services Task Force (USPSTF) is inviting public comments on a draft research plan to update its 2018 recommendation statement on screening for prostate cancer. As I wrote in a previous blog post, the USPSTF’s decision to partially reverse its previous stance recommending against PSA-based screening was based on little new data. Since then, follow up of trials of localized prostate cancer treatments has shown no mortality benefits for immediate surgery or radiotherapy compared with active surveillance for 15 years after diagnosis. In the October issue of American Family Physician, a POEM on the UK ProtecT study results reports that 40 out of every 100 trial participants who selected active surveillance avoided surgery or radiotherapy, with no increase in the risk of death and a small increase in the risk of developing metastatic disease.

New questions that the USPSTF intends to review for this update involve the impact of pre-biopsy prostate cancer risk calculators or magnetic resonance imaging (MRI) on prostate biopsy rates, morbidity and mortality, quality of life, and function. A 2022 Diagnostic Tests article examined the utility of multiparametric MRI (mpMRI) for the evaluation of prostate cancer. A subsequent study found that routinely performing MRI prior to prostate biopsy in Sweden reduced biopsy rates, increased the detection of higher-grade (Gleason score 7 or higher) tumors, and decreased the detection of lower-grade (Gleason score 6) tumors. However, a UK study found that 1 in 6 asymptomatic men between the ages of 50 and 75 invited for a “prostate health check” had a prostate lesion detected on MRI, raising concern that this test may not be a panacea for reducing overdiagnosis.

The American Urological Association (AUA) updated its guidelines on prostate cancer screening and considerations for a prostate biopsy earlier this year. The AUA continues to recommend offering PSA screening every 2 to 4 years to patients aged 50 to 69 years and repeating a newly elevated PSA test before further testing, imaging, or biopsy. It gives a conditional recommendation for use of mpMRI prior to initial biopsy:

In anticipation of more definitive data, it is reasonable to obtain an mpMRI in biopsy-naïve patients prior to their first biopsy, but such a practice cannot be regarded as the standard approach based on the currently available evidence.

In the meantime, how should primary care physicians approach patients who are potentially eligible for screening? The current issue of the Annals of Family Medicine includes a scoping review on patient communication preferences for prostate cancer screening discussions. Based on an analysis of 29 studies, the researchers identified four main themes of successful discussions: using everyday language, receiving enough information, spending sufficient time, and having a trusting and respectful relationship. Notably, they found that without physician prompting, “men rarely considered possible downstream consequences if they screened positive.” Obstacles to robust screening discussions included patients having already decided to pursue screening, being passive in medical encounters, and perceiving threats to masculinity and longevity in these conversations.

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This post first appeared on the AFP Community Blog.

Coronary artery calcium is a common finding in older adults

The 2018 American College of Cardiology/American Heart Association cholesterol management guidelines advised that for patients with an intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk (7.5% to 19.9%), a coronary artery calcium (CAC) score can be used to guide the decision to start or defer statin therapy:

If the CAC score is zero, statin therapy should be withheld or delayed unless the patient is a cigarette smoker, has diabetes, or has a strong family history of premature ASCVD. A CAC score of 1 to 99 suggests statin therapy, particularly for patients 55 years and older. If the CAC score is 100 or greater or in the 75th percentile or greater, statin therapy is indicated for any patient unless otherwise deferred by the outcome of the physician–patient risk discussion.

This recommendation to selectively incorporate CAC scoring into ASCVD risk management has been controversial; the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence that adding the CAC score to traditional risk assessment improves patient-oriented outcomes. In a previous American Family Physician editorial, Drs. John Mandrola and Andrew Foy argued that “it is unclear if knowing the coronary artery calcium score would improve decision quality or adherence to statin therapy.” However, a recent Diagnostic Tests article by Dr. Hu Ying Joanna Choi concluded that “CAC score is a strong predictor of coronary heart disease, CVD, and mortality risk and provides risk discrimination and stratification beyond that provided by traditional risk factor models.”

Incidental detection of CAC on chest computed tomography (CT) scans performed for other reasons in persons without clinical ASCVD was demonstrated in a previous study to increase statin prescriptions, cardiology clinic visits, and stress tests. Until recently, however, the prevalence of CAC in asymptomatic adults was not known. Using data from the National Institutes of Health-sponsored Multi-Ethnic Study of Atherosclerosis in persons aged 45 to 84 years without ASCVD symptoms at baseline, Dr. Matthew Tattersall and colleagues calculated CAC prevalence by age, sex, race, and ethnicity. They found that across all groups, most men in their early 60s had detectable CAC, and the majority of women had CAC by their early 70s. Nearly all (96 to 98%) non-Hispanic White adults in their early 80s had CAC.

The study authors concluded the following:

[A]lthough CAC presence is associated with increased ASCVD risk regardless of age, CAC is common as age increases. Its detection provides an opportunity to discuss ASCVD risk but should avoid provoking unnecessary patient anxiety.

Further,

given the high prevalence of CAC at older ages, a finding of CAC on a CT scan should not reflexively result in a specialist referral or a prescription for a statin and/or aspirin, but rather a comprehensive ASCVD risk assessment with consideration of competing risks and patient preferences.

Clinical summaries of current USPSTF recommendation statements on statins and low-dose aspirin for primary prevention of ASCVD in adults are available on the AFP website.

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This post first appeared on the AFP Community Blog.