The Infomercial Comes to The Wall Street Journal
On April 26, 2023, Bobby Jindal and Chirag Parghi declared, on the opinion pages of the WSJ, that “Mammograms Can Promote Heart Health.” I’m a doctor who has referred hundreds of women for mammograms. Why didn’t I know this? Have I been neglecting the medical literature?
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The authors continued, “Calcium deposits in breast arteries can indicate a problem.” The authors call for action by federal regulators. “The Centers for Medicare and Medicaid Services should make establishing payment codes for products involving women’s heart disease a priority to prompt private insurers to cover new service lines.”
Stop for a minute to reflect on how absurd this is. For calcium deposits in breast arteries to be important, we would need to know that some action based on this finding, whether it be further diagnostic testing, lifestyle modification, or medical therapy, actually benefits a woman.
What would I foresee as happening if CMS took action? Mammography providers would use artificial intelligence technology to quantify breast artery calcification and would add that service to the charge they currently bill. Insurers will be forced to raise rates to cover this new charge. Referring doctors, and patients, will see reports that say “increased breast artery calcification. This finding suggests an increased risk of coronary artery disease; clinical follow up recommended.” The doctor will feel obligated to directly measure arterial calcium where it really matters – in the coronary arteries – and will order a CT exam to measure coronary calcium. Positive tests will result in referrals to cardiologists, followed by stress tests, echocardiograms, and coronary angiograms, and likely percutaneous coronary artery interventions – all of this in asymptomatic persons. All of this with no evidence that this course of action will benefit patients.
We currently assess an asymptomatic woman’s risk of future coronary events by traditional risk factors -- history (age, family history, menopausal status, smoking, exercise habits, diabetes), physical examination (blood pressure, clinical evaluation of circulation), and standard lab tests (cholesterol levels, hemoglobin A1C.) Many non-traditional risk assessment tools have been proposed. One of them, the coronary artery calcium score (CAC) was reviewed in 2018 by the U.S. Preventive Services Task Force (USPSTF), an independent task force of academics and practitioners whose review process is transparent, widely accepted, and untainted by conflicts of interest. The USPSTF concluded that “the current evidence is insufficient to assess the balance of benefits and harms of adding the … CAC score to traditional risk assessment for CVD in asymptomatic adults to prevent CVD events.” We simply don’t know whether using this test will do more good than harm.
The CAC score actually assesses calcium in the coronary arteries. If we don’t know if these measurements are beneficial, why would we assume that breast artery calcium, a proxy for coronary artery calcium, is a reliable guide to care?
Jindal and Parghi are urging the federal government to issue codes that turn the tap on a substantial flow of money from the general public to companies that use artificial intelligence to quantitate breast artery calcium, or that employ cardiologists and offer many well-reimbursed tests to evaluate the significance of that breast artery calcium, and offer interventional procedures to address any abnormalities found.
If this would not help patients, whom would it help?
The article’s post-script makes it easy for us. “Dr. Parghi is a breast radiologist and the chief medical officer of Solis Mammography.” Last year Solis, “the largest independent provider of breast screening and diagnostics in the U.S.,” inked a deal with iCAD, “a global medical technology leader providing innovative cancer detection and therapy solutions,” to use mammography to identify cardiovascular risk. iCAD’s CEO promised that the partnership “will not only offer the potential to address a significant unmet need in patient care but also to penetrate a sizeable new market.” The USPSTF might beg to differ about the significant unmet need, but we can all agree about the sizable new market. Investors take note.
The co-author is not a physician or scientist, but is no stranger to the health care industry. “Mr. Jindal served as governor of Louisiana, 2008-16, and a U.S. assistant secretary of health and human services, 2001-03. He serves on the board of U.S. Heart and Vascular, a provider of cardiovascular services.” U.S. Heart and Vascular is a physician practice management company. Such companies attract capital and partner with existing medical groups. Doctors get cash up-front, stock in the company, and management services. The company employs the non-physicians, acquires the assets, and takes a cut of revenues as their management fee. It is in the interests of the company and the doctors to maximize the revenue by attracting new patients and expanding the billable services provided to them. A deluge of women concerned about their breast calcium score is just what the doctor, and the management company, ordered.
As of 2 years ago, healthcare expenditures in the United States reached $12,914 per person – 18.3% of our Gross Domestic Product. Health care competes with national defense, education, transportation infrastructure, food, education, entertainment, and everything else that we need and value. All of these will wither as we funnel dollars into unproven new medical technology.
Mark Buchanan, MD is an internal medicine physician. Now retired from clinical care, he teaches ethics at the University of Connecticut School of Medicine.