Steven E. Nissen, MD

In June 2014, the advocacy group Public Citizen sent letters to 20 hospitals in eight states asking them to sever relationships with a company that performs mobile health screenings, describing such programs as "unethical" and "causing more harm than good." Additionally, Public Citizen sent a letter to the Joint Commission asking the organization to investigate whether the mobile health-screening corporation has misled consumers by claiming that the program was Joint Commission–accredited.¹ The initiative by Public Citizen received considerable (and appropriate) press coverage, bringing much-needed public attention to an important problem corrupting the American health care system. Under the guise of encouraging wellness, many prominent health care institutions have promoted inappropriate and unethical screenings as a means to attract patients. It's time to end such practices.

These programs typically focus on cardiovascular diseases. For a mere $179, the company cited in the Public Citizen initiative offers a minimum of six screening tests² to everyone who signs up:

• echocardiogram
• electrocardiogram
• carotid artery ultrasound
• abdominal ultrasound
• arterial "stiffness" testing
• ankle brachial index measurement

You can also buy a more expensive "Men's Package" ($347) that includes additional screening tests such as serum testosterone or a "Women's Package" ($347) that adds in measurement of high-sensitivity C-reactive protein and thyroid-stimulating hormone. The value of these screening tests is promoted via the company's website, which includes written and dramatic video testimonials from satisfied customers.

Many health-screening programs operating around the country rely upon similar marketing tactics: use of carefully constructed fear-mongering messages designed to convince a vulnerable population that spending a few hundred dollars could save their lives. Of course, these marketing materials don't tell the public about the thousands of patients who underwent unnecessary and sometimes risky testing after a screening program detected an "abnormality." Integral to many screening programs is a partnership with a health care institution to provide the additional (and often expensive) subsequent testing for patients "identified" during screening. The benefits to the partnering institutions are crass and financially lucrative, specifically the referral of new patients for the previously mentioned well-remunerated testing procedures.

With respect to the ethics and value of health screenings, the science and guidelines are strikingly clear. The ACC, in partnership with several subspecialty imaging societies, has carefully developed guidelines that classify routine echocardiography in asymptomatic individuals as "inappropriate." The US Preventive Services Task Force strongly warns against performing either routine electrocardiography or carotid ultrasonography in low-risk, asymptomatic adults. Several organizations do support limited screening for aortic aneurysms using abdominal ultrasound, but only in selected, high-risk populations such as smokers. An additional concern is the quality of the imaging acquired during a $179 screening session performed in a mobile truck. Thoughtful practitioners are keenly aware of the overhead costs implicit in performing high-quality imaging procedures, including use of expensive equipment and skilled personnel to acquire and interpret the studies.

The issue of mobile screening marketed by "for-profit" companies represents only part of a larger problem. Many prominent and highly reputable health care organizations offer "executive physicals," a comprehensive battery of tests to "high-worth" individuals. According to Bloomberg, executive physicals cost as much as $2,500 or more.³ The price doesn't include all the subsequent costs incurred for evaluating the false-positive findings uncovered by these procedures. These packages often include more elaborate screening procedures, including measurement of carotid intimal medial thickness, routine treadmill stress testing, coronary calcium scanning, and even total body computed tomography (CT) scans.

The inappropriate use of total body CT scans in screening programs has become so problematic that the FDA issued a warning in 2010 stating that:

Taking preventive action, finding unsuspected disease, uncovering problems while they are treatable, these all sound great, almost too good to be true! In fact, at this time the Food and Drug Administration (FDA) knows of no scientific evidence demonstrating that whole-body scanning of individuals without symptoms provides more benefit than harm to people being screened.⁴

Misuse of coronary calcium scoring also has been the subject of investigations by the media.⁵

Current guidelines support only a few simple screening cardiovascular tests in most individuals, including measurement of cholesterol levels and blood pressure. The proliferation of inappropriate screening is largely an artifact of our fee-for-service health care system that emphasizes payment for procedures, rather than health maintenance.

How should thoughtful physicians address mass screening programs? We should educate our patients that a healthy lifestyle is far more useful than a series of unneeded tests that may cause more harm than good. Importantly, we should warn patients that radiation received during any screening test has potentially serious long-term consequences. We should encourage our local health care institutions to avoid partnering with unscrupulous mobile screening operators, regardless of the perceived marketing benefits. The short-term financial gain comes with adverse consequences for patients and the potential to seriously undermine the health care facility's reputation.

References

1. Letter to Mark R. Chassin, MD, President and CEO of the Joint Commission. Available at www.citizen.org/documents/2207.pdf.
2. HealthFair Screening Packages. Available at www.healthfair.com/health-screenings/packages/.
3. Graham T. "Physicals at $2,500 Lure Executives with Thorough Scans." May 30, 2013/ Available at www.bloomberg.com/news/2013-05-20/physicals-at-2-500-lure-executives-with-thorough-scans.html.
4. "Full-Body CT Scans - What You Need to Know." Available at http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115340.htm.
5. Allen M. "Body Imaging Business Pushes Scans Many Don't Need — Including Me." June 7, 2011. Available at www.propublica.org/article/heart-check-america-drawing-complaints-and-scrutiny/single.

Steven E. Nissen, MD, is chair of the Department of Cardiovascular Medicine at the Cleveland Clinic and co-author of Heart411: The Only Guide to Heart Health You'll Ever Need.