I almost never “surf the net” and have no idea what’s
circulating unless someone forwards something they want me to know about. That’s how I ended up watching a YouTube video
http://www.youtube.com/watch?v=6e3udzHIiVs
in which Dr. Jill Vecchio rails against the Supreme Court’s decision regarding
the Affordable Health Care Act.1 When I last looked, the video had
been viewed more than 750,000 times.
For a
video less than three minutes long, it contains a remarkable number of
misleading statements about the Affordable Health Care Act and screening
mammography. I’m dismayed by the number of individuals who have viewed the
video and by Dr. Vecchio’s not-so-subtle threats that if President Obama is not
defeated and the Health Care Act not overturned, we all will be abandoned by our
physicians. It’s to counteract the misleading statements and her threats that
I’ve written this post. Please forward it to others if you think they might
find it useful.
Dr. Jill Vecchio
Dr.
Vecchio is one of 28 radiologists at Rocky Mountain Radiologists, a professional
corporation located in Denver, Colorado.
Rocky
Mountain Radiologists provides services to imaging centers in the Denver
metropolitan area and much of the northwest corner of Colorado. It reviews films
read by non-radiologists for a multitude of private practices and urgent care
centers throughout Colorado and has recently expanded to other states and
countries outside the U.S.2 It also provides, for a nominal
fee, a condominium in Steamboat Springs so its employees can enjoy the ski
slopes.3
Dr.
Vecchio specializes in “Women’s Imaging” and mammography at Rocky Mountain
Radiologists. And she is Director of the Exempla Lutheran Breast Care Center in
Wheat Ridge, Colorado.4
The Video
Taxing is not forcing. Near the
beginning of her video Dr. Vecchio implies that “by taxing, they are forcing us….”
I’m not sure exactly what she thinks we’re being forced to do by the Health
Care Act. But whatever it is she thinks it is doing, the Affordable Health Care
Act is not forcing anyone to participate in a Federal health insurance program.
Section 1555 of the Act explicitly states that “No individual, company,
business, nonprofit entity, or health insurance issuer offering group or
individual health shall be required to participate in Federal health insurance
program created under this Act (or any amendments made by this Act), or in any
Federal health insurance program expanded by this Act (or any such amendments),
and there shall be no penalty or fine imposed upon such issuer for choosing not
to participate in such programs.”
If
someone however, chooses not to have any health insurance at all, they will
have to pay a penalty. Originally this was known as the “shared responsibility
requirement” or “individual mandate.” On June 28, 2012, it was renamed by the
Supreme Court as a “tax” on those who do not have health insurance.
According
to the Act, starting January 1, 2014 all individuals not covered by health
insurance plan (employer-sponsored, Medicare, Medicaid, other public insurance
programs or an approved private insurance policy) will be required to pay a
penalty---unless he or she is a member of a recognized religious sect exempted
by the Internal Revenue Service or the least expensive policy would exceed 8%
of their income. The annual penalty will be $95, or up to 1% of income over the
filing minimum whichever is greater and will increase to a minimum of $695
($2,085 for families) or 2.5% of income over the filing minimum by 2016.
Near
the end of her video Dr. Vecchio appears to be making some kind of dire warning
about employers. Again, I’m not sure what she’s talking about, but I think it’s
probably the penalty which companies with more than 50 employees will have to
pay if they should decide not to offer health Insurance. The tax is $2,000 for
each full-time employee. The first 30 employees however, are exempted. And, very
small businesses will be able to get subsidies if they decide to purchase
insurance through an exchange. Again, as for individuals, businesses are not
forced to provide insurance for their employees. But they, like individuals who don’t want
health insurance, will have to pay a tax.
Given
its recent expansions, I wouldn’t be surprised if Rocky Mountain Radiologists
P.C. has more than 50 employees and will be required to either offer health
insurance to their employees or pay the tax if it should choose not to---putting
Dr. Vecchio in a position of conflict of interest.
Mammography screening guidelines. Dr.
Vecchio claims that the Health Act makes her violate the Hippocratic Oath and that
she will be jailed, fined or not paid if she abides by the Hippocratic Oath instead
of the Health Act. As far as I can tell, there is nothing, not one word, in the
Health Act that says anything about doctors’ being fined or jailed. I searched.
As of September
23, 2010, all new insurance plans began covering preventive care and medical
screenings rated Grade A or B by the U.S. Preventive Services Task Force. Grade A preventive services are recommended because “there is a high
certainty that the net benefit is substantial;” Grade B services are
recommended because “there is a high certainty that the net benefit is moderate
or there is moderate certainty that the net benefit is moderate to substantial.”
(Grade C is “no recommendation” Grade
D, a “recommendation against, and
Grade I---no recommendation due to
insufficient evidence”) Note the provision is directed to insurers, not
physicians.
The
Task Force recommends biennial, not annual, screening mammograms for women age
50-74 (Grade B). And, it does not recommend any regular (biennial or annual) mammography
screening for women age 40-49 (Grade C) or over the age of 74 (Grade I). However,
the Task Force guidelines do permit physicians to use their discretion for
preventive services that receive a lower grade.
So, Dr.
Vecchio will not be fined. She will not
be jailed. But she may not be reimbursed by insurance companies for yearly
mammograms and mammograms for women in their 40s or over 74. Unless her
patients are willing to pay out-of-pocket for non-recommended screening
mammograms, her income could be reduced--- again placing her in a position of
conflict of interest. Thus, it is not surprising that in the video she advocates
for the American Cancer Society’s guidelines which recommend “yearly mammograms
starting at age 40 and continuing for as long as a woman is in good health.”
5
Why the different guidelines? The
American Cancer Society is a non-profit organization. It has a Board of
Directors and is supported by donations. It is the oldest non-profit
organization in the U.S.6 It
has been a major funder of cancer research; 46 of the cancer researchers it has
supported have gone on to win the Nobel Prize.7 Unlike the U.S.
Preventive Services Task Force however, it’s not a group of scientists and physicians
specializing in preventive care. Nonetheless, it has played an important part
in the history of cancer prevention in the U.S. and worldwide.8
After finding evidence of a relationship
between tobacco smoking and cancer in the late 1940s, it battled the cigarette
companies and took upon itself the fight to reduce cigarette smoking in the
U.S. And since the 1950s, the Society has
been instrumental in persuading women to have pap smears to prevent cervical
cancer. Unfortunately, I think the overwhelming success of cervical screening may
have led the American Society and many others to have unrealistically high
expectations of early detection for breast cancer.
Breast
cancer is not like cervical cancer. Cervical cancer tends to be indolent (i.e.,
it develops very slowly) and starts as a precancerous condition (dysplasia) that
happens to be 100% treatable.9 Since it’s indolent, it’s not that urgent it be
found early. In fact, cervical screening works well even if women don’t have pap
smears every year--- which is good because many women don’t.
In the case of breast cancers however, only
some are indolent. Others are aggressive. And, by the time they’re large enough
to be detected by mammography, neither indolent nor aggressive breast cancers
are 100% treatable or precancerous (except for some in situe breast cancers).
Even
the American Cancer Society itself has been ambivalent about breast cancer
screening. In the 1970s it urged annual mammography screening for women 35 and
older. When it learned radiation was
carcinogenic and mammography could cause adverse side effects, it changed its
recommendation to annual mammography screening for women 50 and older in 1980.
But by the 1990s it had almost completely reverted to its previous position and
is now recommending annual mammography screening for women 40 and older.
I don’t
know what’s influencing the Society’s current stance on screening mammography.
One hypothesis is that it’s still overwhelmed by the success of its cervical
screening drive. Another possibility is, as in the case of Dr. Vecchio, conflict
of interest.
The
American Cancer Society is the richest non-profit organization in the United
States.10 In 2010, its net assets totaled $1.3 trillion; its total
revenue equaled $919,264,859, and it paid its chief executive officer
$2,081,246.11 Five of its past presidents have been radiologists and
many of its decisions appear to have reflected the interests of the major
manufacturers of mammogram machines and films (Siemens, DuPont, General Electric,
Eastman Kodak and Piker). Members of the mammography industry have donated large
sums of money, sat on American Cancer Society advisory boards and conducted research
for the Society and its grantees.10
Furthermore, pre-menopausal women, in
particular, appear to be an important target. An
American Cancer Society advertisement in a leading Massachusetts newspaper
featured a photograph of two women in their twenties promising that early detection
will result in a cure “nearly 100 percent of the time.” In an article published
by the Massachusetts Women’s Community’s journal, Cancer, an American Cancer Society communications director when
responding to journalist Kate Dempsey’s question, revealed, “The ad isn’t based
on a study. When you make an advertisement, you just say what you can to get
women in the door. You exaggerate a point….Mammography is a lucrative [and]
highly competitive business.”10 Apparently premenopausal women’s participation
in routine screening contributes half of health care facilities’ annual
revenue.10
Screening effectiveness. Dr. Vecchio
boasts that “just” screening mammography, by itself, decreases the numbers of
deaths from breast cancer by 30-40%. Wow! I wonder what surgeons, radiation
therapists, oncologists, and the pharmaceutical companies would say to that. I
bet they think they’re contributing to the decrease in death rate.
Even if
screening mammography were 100% accurate, it could not, just by itself, prevent
a single death. Before the advent of successful adjuvant chemotherapies and the
discovery of the drug tamoxifen, so few women with breast cancer survived, it
was difficult to tell if screening had any effect at all on the death rate.
According
to the report accompanying the U.S. Preventive Service Task Force’s new
guidelines, there’s a 39.4% reduction in mortality for women age 40-84 when
they are screened annually. But that’s versus NO screening at all. That’s not what we’re talking about here. What’s
important here is the difference in the reduction of mortality between women
who are screened annually (the American Cancer Society guidelines) versus those
who are screened biennially (the U.S. Preventive Services Task Force Guidelines).
According to the Task Force’s report, there’s
a 31.8% reduction in mortality for women age 40-84 when they are screened
biennially. The difference between the two screening strategies is a 7.8%
reduction in mortality. Given that 3% of women who are not screened die of breast
cancer, it means that 2.34 fewer women per 1000 will die of breast cancer if
they’re screened annually rather than biennially.
The costs of the additional 17,842 mammograms needed
for annual screening are: 1,398 false positives; 1,198 women undergoing
unnecessary additional imaging; and 86 women having unnecessary biopsies. The
costs of the additional exposure to ionizing radiation are more difficult to
assess. Experts don’t agree on how to
measure the effect of mammography radiation on breast tissue.
I’m
confident of only three things about the danger of mammography screening itself
leading to the development of breast cancer. The first is that annual rather than biennial screening
doubles the risk of ionizing radiation leading to the development of breast
cancer. The second that, specifically for the case of women age 40-84, the
probability of one mammogram leading to breast cancer must be very small, less
than 0.01%. If it’s equal to or greater than that, annual mammography could
potentially lead to more breast cancers than the number of additional lives it
saves. And the third is that the probability of mammography leading to breast
cancer is higher for premenopausal women than postmenopausal women. Experts do
agree that the premenopausal female breast is one of the most radiosensitive
organs in the body
Threats. At the beginning
and the end of her video Dr. Vecchio suggests that if President Obama is
re-elected and the Health Act not overturned, hundreds of thousands (possibly 800,000)
physicians will close up shop and leave us all in the lurch because they, like
she, will be forced by the Health Act to violate the Hippocratic Oath.
Will we
be abandoned by our doctors if the Health Care Act remains the law of the land?
Probably we will be by some, but probably not by all 800,000. Their past track
record hasn’t been that great though.
In 1937, President Roosevelt signed the
National Cancer Institute Act. It established a National Advisory Council. Four
of its six members were American Cancer Society Directors. That year, many
doctors, worried that the Society’s alliance with the government might lead to
socialized medicine, stopped donating to the Society.8
In 1944, the California Medical Association hired
Whitaker and Baxter, founders of Campaigns Inc., the first political consulting
company in the world. H.R. Haldeman, the
person who ran Nixon’s presidential campaign, learned the tools of his trade
from Whitaker and Baxter. The Association paid Campaigns Inc. $45,000 a year to
scuttle Governor Earl Warren’s proposal for a comprehensive, compulsory health
insurance plan in California.12
The following
year, the American Medical Association paid Whitaker and Baxter $100,000 a year
to fight President Truman’s health care plan for the country’s children. The
Association assessed each of its members $25.00 a year to raise the money.
12
To
their credit, a number of doctors resigned. Dr. James Means, Professor of
Medicine at Harvard and Chief of Medicine at Massachusetts General Hospital,
wrote that he was no longer willing to support something “contrary to public
welfare and unworthy of a learned profession.” That fall, the Association let
Baxter and Whitaker go.12
I don’t
know for sure, but I doubt that that many physicians will give up their profession
if President Obama wins the coming election and the Health Act remains the law
of the land. I even doubt that Dr. Vecchio will. If some do though, I believe,
in the long run, we will all be much better off without them than without the
Health Act.
Why 750,000+ hits? William
Gavin, another Nixon political advisor, once wrote, “Voters are basically lazy,
basically uninterested in making an effort
to understand what we’re talking about. Reason requires a higher degree of
discipline, of concentration; impression is easier. Reason pushes the viewer
back, it assaults him, it demands that he agree or disagree. Impressions can
envelop him, invite him in, without making an intellectual demand …. When we
argue with him, we demand that he make the effort of replying. We seek to
engage his intellect, and for most people this is the most difficult work of
all. The emotions are more easily roused, closer to the surface, more
malleable.”12 That may explain the 750,000+ hits.
The Hippocratic Oath13
Since the Health Care Act
does not force doctors to do anything; it cannot make them violate the Hippocratic
Oath. If a doctor advises a patient to have a treatment that is not covered by
insurance and the patient wants that treatment and is willing to pay for it, there
is no problem. No one will be fined. No one will be jailed. The doctor will be
paid. And the Hippocratic Oath will not be violated.
The
Oath, on the other hand, does constrain doctors. It includes a promise “to
abstain from doing harm.” That means that radiologists who, like Dr. Vecchio,
specialize in screening mammography, must take into account screening’s potential
harms for pre-menopausal women.
Even I,
who was less than enthralled by the U.S. Preventive Services Task Force
research and guidelines, found its research and conclusions regarding women in
their 40s convincing. The data show that too many women in their 40s have to be
screened to detect one cancer---556 versus an average of 198 mammograms for
women 50-89 years old---and too many undergo additional imaging; 47 versus an
average of 14 for women 50-89 years old. And, apparently pre- and post-menopausal
breasts are so different, premenopausal screenings are even useless for baseline
comparisons.
Conclusion
It
seems clear to me that by not recommending regular mammograms for women age
40-49, the U.S. Preventative Services Task Force guidelines are protecting the
health of premenopausal women and, by using the Task Force’s guidelines, the
Affordable Health Care Act is doing a better job of preventing harm and upholding
the Hippocratic Oath than Dr. Vecchio appears to be able or willing to do.
References
12 Lepore, Jill, (9/24/12). The Lie Factory, The
New Yorker, pp. 50-59.
13 http://en.wikipedia.org/wiki/Hippocratic_Oath
