It can be amusing when people mistake the map for the territory (sometimes called the reification fallacy). When it harms my patients, though, it pisses me off. And it isn’t just me, or my institution: two physician friends (in other states) tell me they are seeing it as well.
Colorectal cancer (CRC) is a bad disease. Among cancers it is unusual: we have the ability not just to find it early when it is easier to treat successfully, but actually to find and remove the precursors to cancer, preventing the cancer, and avoiding the need to treat it. The USPSTF and the CDC advocate screening.
The standard screening is colonoscopy (CN) but there are alternatives. Most clinicians strongly support colorectal cancer screening starting at 50 (or 10 years before a first degree relative developed disease) because both our experience and the data show it to work. Patients are less impressed and our national CRC screening statistics are not the success story we would like.
The Centers for Medicare and Medicaid Services (CMS) and others active in public health and health policy see improved screening as a goal for both humanitarian reasons (save lives) and financial reasons (save money). I agree. CMS and others in public health would like us to improve our performance by increasing the number of eligible patients who are screened and treated appropriately. Again, I agree.
To address this, they have instituted financial incentives for institutions and clinicians to sell CRC screening to patients. (I have written before about my concerns with the ethics of P4P and the problem with incentivizing a specific decision rather than a shared decision, here.)
Near the end of every incentive reporting period, we see a flurry of activity aimed directly at meeting quality metrics and often with little regard for patients. (Making sure our map looks good but ignoring the problems with the territory it represents.) In the case of CRC screening, this takes the form of telling patients who decline CN, or who cannot get it done in time (currently we have a 4 month wait in our community) to help the clinician receive his incentive payment, that there is an easier way: FIT testing. It’s easy. Done at home. No nasty prep. No time lost from work. Covered by your insurance. And extremely (90%) sensitive - very little risk that we will miss disease. Sounds almost too good to be true. The focus becomes encouraging high participation in the screening, thus maximizing revenue for the institution and guaranteeing incentive payments for the clinician. Butscreening does not save lives. And here is where we go off the rails. We are selling a test that may not be in the best interest of the patient, and selling it because it is in the best interest of the clinician and the institution that pays his salary.
What is wrong with pushing for FIT testing?
We are so interested in making screening look easy and good that we blow past the fine print. We forget to tell them that FIT testing has to be done every year, not once every 10 years like the CN. We forget to tell them that there are false positives, in ~ 4 out of 100. And that if you have a positive, the FIT test is just a screening test, so you will still need that colonoscopy you were trying so hard to avoid. And that if it is positive and you now need a colonoscopy, it will be a diagnostic CN to find the source of the blood and not a screening CN. So what? There’s a potential major difference between a screening and diagnostic colonoscopy: cost. Although the test itself is exactly the same for the doctor and the patient, it is very different for the insurer. Insurers are required to cover screening CN with no co-pay or deductible, so it is free for the patient. Most insurers, however, apply both co-pay and deductible to all diagnostic tests, including CN. This means that the patient will often be responsible for a substantial portion (or even all) of the cost. Oh, and at 4/100 having a false positive every year, and doing this every 10 years, it means that a patient has a nearly 50/50 chance of having a (+) and needing a diagnostic CN within 10 years (by 60) and a nearly 100% chance over the 25 years until they reach the age of 75 (when most patients stop).
I now have a couple patients who were encouraged to have FIT testing, had a (+), and now cannot afford the diagnostic CN. Their screening has benefitted me and my institution, but these patients are worse off, worrying about a potentially fatal disease they might have, but not able to find out. And the institution that so badly wanted the map to look good (maximize the percent screened) is suddenly not interested in the territory (the actual patient) and walks away, feeling no responsibility for the screened but unevaluated patient.
So, when leadership and management and QI officials at your hospital focus on metricslike screening percentages (the map) rather than on what is best for individual patients (the territory), the metrics are likely to change. The hospital will increase its revenue stream. The clinicians will qualify for bonuses. But this will happen at the expense of patient welfare.
We have truly lost our way in medicine.