Have you ever heard of someone whose insurance premiums went up after undergoing additional tests recommended by their doctor following a routine checkup? In the United States, prior to 2014, when the Affordable Care Act (ACA) took full effect, individuals with private health insurance could face higher premiums or be denied coverage if a medical test indicated they were at high risk of developing a certain disease in the future, even if they did not actually develop that disease. Currently, such practices are prohibited under health insurance; however, in life insurance, disability insurance, and long-term care insurance, premiums may increase or applications may be denied based on test results.
We often hear stories of people whose lives were saved by tests they underwent “just to be safe” or by additional tests recommended by their doctors. However, on the flip side, additional tests can sometimes lead to adverse effects, such as physical strain or financial burden.
Prostate cancer is a disease that rarely causes symptoms in its early stages. By the time symptoms such as urinary problems or bone pain appear, the cancer has often already progressed. For this reason, PSA (prostate-specific antigen) testing is performed based on the premise that measuring PSA levels through a blood test and detecting and treating the cancer before symptoms appear can reduce mortality.
However, since PSA levels can rise due to inflammation or an enlarged prostate, even in the absence of cancer, there are many false positives (cases where the result is abnormal even though there is no cancer). In addition, many slow-growing cancers that would never cause harm are detected (overdiagnosis). A biopsy, which is the next step in diagnostic testing, carries a risk of infection; approximately one in 100 patients is hospitalized, primarily due to infection.
For these reasons, the U.S. guidelines (USPSTF) state that individuals aged 55 to 69 should decide for themselves whether to undergo the test after being informed of the benefits and risks, while the test is not recommended for those aged 70 and older. In practice, however, PSA testing is often included in annual health checkup blood tests without adequate explanation, and this has become a cause for concern. Even though the person has no intention of “going through with it,” the test results come back, and that triggers a “chain reaction of tests” in which one additional test follows another.
Lung cancer CT screening has similar aspects. In the National Lung Screening Trial (NLST) conducted by the U.S. National Cancer Institute (NCI), approximately 53,000 people aged 55 to 74 who were heavy smokers (with a smoking history equivalent to “one pack a day for 30 years” or more) and had no signs or symptoms of lung cancer underwent screening once a year for a total of three times. As a result, approximately one in four low-dose CT scans was classified as “positive,” but more than 96% of those were not cancer (false positives). Over the course of three years, this means that about 40% of people were told at least once that they had “abnormal findings.”
Many of the follow-up tests performed on individuals who tested positive involved additional CT scans, which increased the number of times they were exposed to radiation. Some individuals also underwent invasive procedures, such as needle biopsies, bronchoscopies, and open-chest surgery. Some of them experienced serious complications, including respiratory failure, heart failure, myocardial infarction, pulmonary embolism, and organ damage.
Of the approximately 17,000 positive test results that turned out not to be cancer, serious complications were rare, occurring in 12 cases (about 0.1%); however, six people died within 60 days of undergoing follow-up testing even though they did not have cancer (it is unclear whether the testing was the cause of death).
Cataract surgery is a quick procedure that places minimal strain on the body and is typically performed under local anesthesia, such as with eye drops. Even so, there are doctors and hospitals that routinely perform an electrocardiogram (ECG) before surgery. However, research has shown that performing this test uniformly before surgery does not improve surgical safety, and since 2002, guidelines from multiple professional medical societies have deemed it unnecessary.
The reason this practice continues is that it is a remnant of a time when it was considered prudent to examine cataract patients “thoroughly,” since many of them are elderly and have underlying medical conditions. In addition, in some cases, the decision is based on facility policies rather than an individual doctor’s judgment. If a surgical center has a blanket rule, such as “all elderly patients must undergo an electrocardiogram”, doctors have no choice but to follow it.
A study of approximately 110,000 older adults in the United States found that about one in six people who had an electrocardiogram (ECG) before surgery underwent additional cardiac testing, saw a cardiologist, or received cardiac treatment within the following three months. Just as with the PSA test, a single test is triggering a “chain reaction” of further testing.
Many point out that the reason some doctors and hospitals recommend unnecessary tests is the “fee-for-service” system, under which they are paid for each test or procedure performed. This is the basic structure of healthcare payment in the United States: when a doctor performs an electrocardiogram, they are paid a fee for that service. It has long been pointed out that, since income increases with the number of tests performed, there is little incentive to reduce tests that are not medically necessary.
As a measure to address this issue, a “pay-for-performance” system (a type of value-based payment) was introduced, under which reimbursement is based on the quality of care rather than the number of tests performed. However, it has been pointed out that, since participation rates in recommended screenings (such as mammograms and colorectal cancer screenings) are now factored into evaluations, this creates pressure to ensure “everyone undergoes these screenings,” regardless of each patient’s individual circumstances.
As such, it’s important to carefully evaluate any tests recommended “just to be safe.” Under the current medical reimbursement system, it is difficult to quantitatively assess whether a test is truly necessary for a particular patient, so there is an inherent tendency to prioritize “just having the patient undergo the test.” If a test is recommended, it is a good idea to ask your doctor, “What will this test reveal that we don’t already know?” and “How will the results change my treatment or course of action?” If the answers are unclear, it is reasonable to conclude that there is little point in undergoing the test.
However, the screenings discussed here are primarily intended for people without symptoms. The situation is different if you have concerning symptoms, such as chest pain or changes in your physical condition, or if your doctor has told you that you are at particularly high risk. We recommend that you do not decide to skip a screening on your own, but rather discuss both the benefits and risks thoroughly with your doctor before making a decision.
Reference:
- https://uspreventiveservicestaskforce.org/Home/GetFile/6/250/prostate-cancer-final-rec-statement-bulletin/PDF
- https://cdas.cancer.gov/publications/320/
- https://pmc.ncbi.nlm.nih.gov/articles/PMC6547245
- https://escholarship.org/content/qt8rh7g231/qt8rh7g231.pdf
- https://www.nationalacademies.org/event/10-08-2012/docs/D14EFEDE258BE887EE38020926243C7CD9ED57A970BB?noSaveAs=1
- https://pmc.ncbi.nlm.nih.gov/articles/PMC4593930/table/T1
