Great post! The value proposition assigned to screening complicates the teaching of clinical reasoning too. When preceptors de-prioritize cancer screening because the focus of a visit must shift, learners often feel they’ve ‘missed the mark’ and therefore betrayed a primary care ritual - not unlike missing the Eucharist while at church. Worse, some patients withhold important complaints (‘my body has hives on this new med’) because they want their annual paid for. Amazing what value assignment & payer rewards can do to otherwise smart people with (usually) good judgment. You make strong arguments for studying the flip side of this coin!
Very good discussion. I think a lot of problems are due to a misunderstanding of the purpose of medical care and what it can and can't accomplish. The role of the doctor is to differentiate health from disease, diagnose the disease, offer the choices for treatment, and reassure the healthy. They don't know how to prevent disease and neither does anyone else. The idea that early detection would be helpful was a good one but there is, so far, precious little evidence of any significant benefit and some potential harm. My advice to patients over 40 years of practice was to see a doctor only if you are having problems or questions about your health but otherwise avoid contact with the medical system. No screening tests. No routine physicals.
Incentivized anything is exactly what it is. I remember when “pain is the 5th vital sign,” a measure I was very against, and patient satisfaction scores were measured for pain management, opioid use skyrocketed. We see what happened there. I cannot imagine how hard it is for a PCP to deal with these things among specialties who have different incentives. It makes the N=1 patient tougher to take care of.
When seeing a new patient recently who had a long list of complex medical problems, I laughed and said to her, “you’re kind of scary on paper, but you are lovely in person.” We laughed together and she said that it was so wonderful to hear a doctor laughing because usually doctors are so serious and overwhelmed when they see her. That laughter did more for her than any dumb HEDIS screening I could have done that day. When doctors get to be doctors and not follow cookbooks we can do amazing things. I’m hoping the new crew in HHS can help make some of these changes. Thank you for moving the conversation further along Wil!
Your case illustrates almost all of the reasons that I left my employed position. It is shocking how many of our healthcare dollars go into getting a healthcare dollar from a 3rd party payor. Screening examinations are great, but your patient needed someone to listen to what was going on with them, not what was going on with their payor. It was said above, but he who pays the bill calls the tune. I think this is why direct care work so well.
Intuitively, “screening saves lives,” and it makes sense. But the devil in the details is that it does not save lives. And your piece really presciently illustrates how screening distracts from real medicine.
Insightful, provocative post. Through my training I first bought the mantra of health promotion/disease prevention. The notion of identifying,then interceding early on an asymptomatic population( ie screening) made good intuitive sense. The problem is that we are not any good at it and have a long way to go before effective implementation. Unless policymakers grasp this problem, primary care will be incentivized by well intentioned but misguided directives.
Another incentivized screening practice that distorts the encounter is the Review of Systems that bumps up the reimbursement level of a Medicare follow-up visit. Who benefits from the second or fourth ROS this year except the practice’s revenues? It litters the note with useless verbiage, steals the provider’s attention from the patient’s real issues and, when it is actually done rather than just dry-labbed uses up precious minutes of the visit.
We need compensation programs that reward important patient outcomes or don’t meddle in process incentives at all.
My FQHC incentivizes HIV and hep C screening, which my mostly geriatric population is not interested in. I do not do well in this measure and could increase my take-home pay by wasting our time to convince them to do the screening instead of wasting our time with talk of grandchildren, dogs, and diabetes.
Although to be fair, I have seen no studies that show that asking patients about the people most important to them improves their outcomes either, or that it reduces doctor burnout, but I highly suspect it does both. I'd like to be involved in that study please.
This is a very well-written and thought-provoking post, Wil. PC’s case was especially powerful.
I think that this is an unintended consequence of a very slow shift towards value-based care, for which professional groups (including our AAFP) have been lobbying a long time. It’s very difficult to measure “quality,” so we are left with metrics such as these as a surrogate. Not to mention that many CMS measures aren’t really grounded in solid evidence.
Now, we find ourselves in this weird middle-ground of fee-for-service *plus* fee-for-checkboxes. Meanwhile, patients suffer from distracted priorities.
I don’t know if the at-risk, capitated model is the solution to this problem, but something needs to change.
Screening incentives are intended to maximize uptake of proven preventive interventions. At their best, they save both lives and money. In Kentucky, where smoking rates are among the highest in the nation, our health system has performed nearly 50,000 low-dose lung cancer screens. The results have been striking: a consistent stage migration from patients diagnosed at stage IV — with little chance of long-term survival — to many caught at stage I, where more than 90% survive. Over time, this shift has translated into a measurable mortality benefit in our community.
We also track the other side of the equation. Screening carries risks — unnecessary biopsies, anxiety, cost. By measuring these outcomes alongside survival, we can be honest about both the benefits and the harms. That transparency is what makes the program legitimate and sustainable.
And there’s no ignoring the economics. Screening is probably one of the highest-yield cost-saving strategies we have in medicine. The cost of a low-dose CT scan, a mammogram, or a colonoscopy is a small fraction of what it takes to treat advanced lung, breast, or colon cancer. When screening works, it prevents not just human suffering but immense financial strain on patients and the health system alike.
But this isn’t always how incentives are deployed. Mandated checklists, detached from local context, can crowd out clinical reasoning. Taken too far, incentives risk distracting physicians from high-impact interventions when they matter most. We must not let population health metrics eclipse the art of medicine.
The lesson isn’t to abandon incentives but to wield them carefully: to tailor them to the needs of local populations, to measure outcomes as rigorously as uptake, and to ensure that incentives amplify rather than replace sound clinical judgment.
It seems lung cancer screening is not a HEDIS quality metric yet, but the American Cancer Society and American Lung Association provided an award to NCQA to make it one (like mammography and colonoscopy). Still, lung cancer screening might be catalyzed locally through programs like the Kentucky LEADS Collaborative.
As terrifying as it is to discover a cancerous mass, it is difficult to know which pose a mortal threat. Sometimes, cancer grows too slowly to become life threatening - those individuals may die of something else. Or, the cancer may be too advanced to intervene. In both of these cases, screening, biopsy, surgery, and chemotherapy are logistical, emotional, and financial burdens that do not change the ultimate outcome.
I found Gilbert Welch's book "Overdiagnosed" particularly influential on this topic. It was written before the introduction of low-dose lung CT, but the same principle applies: our goal is to find cancer whose discovery and treatment will lead to longer lives. This is a challenging task, but certainly one worth investigating and pursuing. As of now, I am sympathetic to the views expressed by Dr. Prasad here:
When LEADS was introduced 10 years ago, I think Kentucky could have done our healthcare system a huge favor if it were deployed in stages, creating a natural experiment or RCT. If the program proved it saved lives in a trial, it could be more confidently funded and expanded across the country. If screened individuals did not in fact live longer, those public health funds could be allocated to other experiments or efforts like smoking cessation. I find it difficult to say when screening saves lives outside the context of a trial.
I think the real takeaway is that it always comes back to the patient in front of you. I don’t order CT scans for someone who has no interest in treatment if we find something. But I’ve also had patients in their late 70s who chose surgery for a high grade non-small cell lung cancer — a minimally invasive robotic procedure that gave them years they never would’ve had otherwise. And even when screening doesn’t save a life, it can spare people from the symptoms that come down the road — cough, shortness of breath, painful bony metastases. It’s such a nuanced discussion but I think we all can agree — first, listen to the patient.
I think you make a lot of great points about the rationale of screening at the population level. However, at the individual level, the benefits are small.
Additionally, the very nature of incentives makes it difficult to “wield them carefully.” At their core, incentives are external factors that are meant to influence behavior. When tied to financial gain, that influence becomes very powerful.
Though well-intended, screening incentives tend to amplify paternalistic practice at the expense of the individual patient.
As a retired FP who still precepts residents in a FQHC I have experienced the above screening conundrums. I frequently have to remind residents to concentrate on the Chief Complaint. Since most screening has minimal impact on All Cause Mortality honing in on the reason for visit seems a better use of the 20 minute visit.
Great post! The value proposition assigned to screening complicates the teaching of clinical reasoning too. When preceptors de-prioritize cancer screening because the focus of a visit must shift, learners often feel they’ve ‘missed the mark’ and therefore betrayed a primary care ritual - not unlike missing the Eucharist while at church. Worse, some patients withhold important complaints (‘my body has hives on this new med’) because they want their annual paid for. Amazing what value assignment & payer rewards can do to otherwise smart people with (usually) good judgment. You make strong arguments for studying the flip side of this coin!
Great post. Guidelines are guidance which should be adapted to individuals. They lose value when turned into cookbooks or rigid protocols.
Very good discussion. I think a lot of problems are due to a misunderstanding of the purpose of medical care and what it can and can't accomplish. The role of the doctor is to differentiate health from disease, diagnose the disease, offer the choices for treatment, and reassure the healthy. They don't know how to prevent disease and neither does anyone else. The idea that early detection would be helpful was a good one but there is, so far, precious little evidence of any significant benefit and some potential harm. My advice to patients over 40 years of practice was to see a doctor only if you are having problems or questions about your health but otherwise avoid contact with the medical system. No screening tests. No routine physicals.
Screening is a public health activity. We are spending our time on asymptotic disease better managed by a population database buocracy.
Patients say they like"prevention but they especially want care for when they feel sick, a very different kind of medicine.
Incentivized anything is exactly what it is. I remember when “pain is the 5th vital sign,” a measure I was very against, and patient satisfaction scores were measured for pain management, opioid use skyrocketed. We see what happened there. I cannot imagine how hard it is for a PCP to deal with these things among specialties who have different incentives. It makes the N=1 patient tougher to take care of.
When seeing a new patient recently who had a long list of complex medical problems, I laughed and said to her, “you’re kind of scary on paper, but you are lovely in person.” We laughed together and she said that it was so wonderful to hear a doctor laughing because usually doctors are so serious and overwhelmed when they see her. That laughter did more for her than any dumb HEDIS screening I could have done that day. When doctors get to be doctors and not follow cookbooks we can do amazing things. I’m hoping the new crew in HHS can help make some of these changes. Thank you for moving the conversation further along Wil!
Such a wonderful post. One that really puts into perspective why primary care feels so difficult to navigate as a patient.
Your case illustrates almost all of the reasons that I left my employed position. It is shocking how many of our healthcare dollars go into getting a healthcare dollar from a 3rd party payor. Screening examinations are great, but your patient needed someone to listen to what was going on with them, not what was going on with their payor. It was said above, but he who pays the bill calls the tune. I think this is why direct care work so well.
Intuitively, “screening saves lives,” and it makes sense. But the devil in the details is that it does not save lives. And your piece really presciently illustrates how screening distracts from real medicine.
Insightful, provocative post. Through my training I first bought the mantra of health promotion/disease prevention. The notion of identifying,then interceding early on an asymptomatic population( ie screening) made good intuitive sense. The problem is that we are not any good at it and have a long way to go before effective implementation. Unless policymakers grasp this problem, primary care will be incentivized by well intentioned but misguided directives.
Another incentivized screening practice that distorts the encounter is the Review of Systems that bumps up the reimbursement level of a Medicare follow-up visit. Who benefits from the second or fourth ROS this year except the practice’s revenues? It litters the note with useless verbiage, steals the provider’s attention from the patient’s real issues and, when it is actually done rather than just dry-labbed uses up precious minutes of the visit.
We need compensation programs that reward important patient outcomes or don’t meddle in process incentives at all.
My FQHC incentivizes HIV and hep C screening, which my mostly geriatric population is not interested in. I do not do well in this measure and could increase my take-home pay by wasting our time to convince them to do the screening instead of wasting our time with talk of grandchildren, dogs, and diabetes.
Although to be fair, I have seen no studies that show that asking patients about the people most important to them improves their outcomes either, or that it reduces doctor burnout, but I highly suspect it does both. I'd like to be involved in that study please.
This is a very well-written and thought-provoking post, Wil. PC’s case was especially powerful.
I think that this is an unintended consequence of a very slow shift towards value-based care, for which professional groups (including our AAFP) have been lobbying a long time. It’s very difficult to measure “quality,” so we are left with metrics such as these as a surrogate. Not to mention that many CMS measures aren’t really grounded in solid evidence.
Now, we find ourselves in this weird middle-ground of fee-for-service *plus* fee-for-checkboxes. Meanwhile, patients suffer from distracted priorities.
I don’t know if the at-risk, capitated model is the solution to this problem, but something needs to change.
Screening incentives are intended to maximize uptake of proven preventive interventions. At their best, they save both lives and money. In Kentucky, where smoking rates are among the highest in the nation, our health system has performed nearly 50,000 low-dose lung cancer screens. The results have been striking: a consistent stage migration from patients diagnosed at stage IV — with little chance of long-term survival — to many caught at stage I, where more than 90% survive. Over time, this shift has translated into a measurable mortality benefit in our community.
We also track the other side of the equation. Screening carries risks — unnecessary biopsies, anxiety, cost. By measuring these outcomes alongside survival, we can be honest about both the benefits and the harms. That transparency is what makes the program legitimate and sustainable.
And there’s no ignoring the economics. Screening is probably one of the highest-yield cost-saving strategies we have in medicine. The cost of a low-dose CT scan, a mammogram, or a colonoscopy is a small fraction of what it takes to treat advanced lung, breast, or colon cancer. When screening works, it prevents not just human suffering but immense financial strain on patients and the health system alike.
But this isn’t always how incentives are deployed. Mandated checklists, detached from local context, can crowd out clinical reasoning. Taken too far, incentives risk distracting physicians from high-impact interventions when they matter most. We must not let population health metrics eclipse the art of medicine.
The lesson isn’t to abandon incentives but to wield them carefully: to tailor them to the needs of local populations, to measure outcomes as rigorously as uptake, and to ensure that incentives amplify rather than replace sound clinical judgment.
Thanks for the comment :)
It seems lung cancer screening is not a HEDIS quality metric yet, but the American Cancer Society and American Lung Association provided an award to NCQA to make it one (like mammography and colonoscopy). Still, lung cancer screening might be catalyzed locally through programs like the Kentucky LEADS Collaborative.
As terrifying as it is to discover a cancerous mass, it is difficult to know which pose a mortal threat. Sometimes, cancer grows too slowly to become life threatening - those individuals may die of something else. Or, the cancer may be too advanced to intervene. In both of these cases, screening, biopsy, surgery, and chemotherapy are logistical, emotional, and financial burdens that do not change the ultimate outcome.
I found Gilbert Welch's book "Overdiagnosed" particularly influential on this topic. It was written before the introduction of low-dose lung CT, but the same principle applies: our goal is to find cancer whose discovery and treatment will lead to longer lives. This is a challenging task, but certainly one worth investigating and pursuing. As of now, I am sympathetic to the views expressed by Dr. Prasad here:
https://www.sensible-med.com/p/i-just-want-to-work-on-my-car
When LEADS was introduced 10 years ago, I think Kentucky could have done our healthcare system a huge favor if it were deployed in stages, creating a natural experiment or RCT. If the program proved it saved lives in a trial, it could be more confidently funded and expanded across the country. If screened individuals did not in fact live longer, those public health funds could be allocated to other experiments or efforts like smoking cessation. I find it difficult to say when screening saves lives outside the context of a trial.
I think the real takeaway is that it always comes back to the patient in front of you. I don’t order CT scans for someone who has no interest in treatment if we find something. But I’ve also had patients in their late 70s who chose surgery for a high grade non-small cell lung cancer — a minimally invasive robotic procedure that gave them years they never would’ve had otherwise. And even when screening doesn’t save a life, it can spare people from the symptoms that come down the road — cough, shortness of breath, painful bony metastases. It’s such a nuanced discussion but I think we all can agree — first, listen to the patient.
I think you make a lot of great points about the rationale of screening at the population level. However, at the individual level, the benefits are small.
Additionally, the very nature of incentives makes it difficult to “wield them carefully.” At their core, incentives are external factors that are meant to influence behavior. When tied to financial gain, that influence becomes very powerful.
Though well-intended, screening incentives tend to amplify paternalistic practice at the expense of the individual patient.
As a retired FP who still precepts residents in a FQHC I have experienced the above screening conundrums. I frequently have to remind residents to concentrate on the Chief Complaint. Since most screening has minimal impact on All Cause Mortality honing in on the reason for visit seems a better use of the 20 minute visit.
This sounds like a raging example of Goodhart’s Law at work.
A related principle: "He who pays the piper calls the tune".
Had to look that one up! Spot on!