“A lot that ends up being found is clinically of no importance at all,” Steven Weinberger, executive vice president and chief executive of the American College of Physicians, wrote in an August piece in the Annals of Internal Medicine. He and two co-authors argued it was “unethical” for hospitals to promote the tests without disclosing potential downsides.
Inova Health System, one of the Washington region’s largest hospital networks, is partnering with a screening company called HealthFair to promote a $139 package of what it describes as “five life-saving tests for heart disease and stroke.” The tests, which usually are not covered by insurance, are performed in specially equipped buses, operated by HealthFair, that travel to different locations carrying the Inova logo.
“We know the incidence of finding a disease where the patient has to do something about it today, or tomorrow, or next week, is very low, but that’s not why we engaged in the screening,” said David Spinosa, an interventional radiologist and medical director of the Inova Heart and Vascular Institute. “If people learn they have early signs of a disease — if their physicians know that — then they have an opportunity to aggressively modify their risk factors.”
He said that about 45 percent of the 8,000 people screened since the program’s inception had some abnormal finding, mostly on the mild side; critical problems were uncovered in fewer than 1 percent of cases.
Inova doesn’t pocket anything from the testing; in fact, it pays HealthFair to put the Inova logo on the buses. But patients can sign a form allowing someone from the hospital group to contact them to discuss abnormal findings, and a list of Inova doctors is available on the buses.
“It’s a way to promote brand awareness and have someone sitting there who can say, ‘I have just the doctor for you,’ ” said Mitch Morris, of Deloitte, a consulting firm whose clients include hospitals. “If they hook someone up with a primary-care physician, that sets up in many cases a lifetime of patronage to that health system.”
Dave Andrews, marketing and public relations manager at Inova Fairfax Hospital, declined to say how much the five-hospital chain pays HealthFair, or how many referrals it gets as a result of the testing.
Similar partnerships between hospitals and screening companies, including HealthFair and Life Line Screening, are taking place in locations such as Richmond and the suburbs of Chicago.
Proponents say that the screenings empower patients by giving them information they need and that they help doctors distinguish themselves from other practitioners.
“Hospitals want to do outreach,” says Joelle Reizes, global communications director at Life Line Screening, an Ohio-based firm that partners with 180 hospitals to offer such screening. “[But] there’s also a philosophical debate here: Do people have a right to know what’s going on inside their bodies and have screenings they feel are right for them?”
But Weinberger and other critics say that such general public screening programs raise health-care costs. Weinberger says they also can spur “additional testing that is harmful.”
Hospitals have long sponsored screenings, sending mammogram units to community events and sponsoring health fairs where people can get their blood pressure tested. There is widespread agreement that some tests — such as those for high blood pressure and diabetes — are safe and effective and that they lead to better health outcomes.
But the five-test basic package advertised by HealthFair is much more elaborate. It includes ultrasound tests for blockages of the carotid artery and weak spots in the abdominal aorta; an electrocardiogram, or EKG; a test of elasticity of the arteries; and another for blockages in arteries serving the legs, a condition called peripheral arterial disease. Similar test packages are offered by Life Line Screening and its hospital partners.
The U.S. Preventive Services Task Force, an independent government panel charged with evaluating such care, recommends against routine use of four of the five tests in adults without symptoms or risk factors. The panel does support the ultrasound looking for abdominal aortic aneurysms — but only for men age 65 to 75 who have smoked.
Additionally, two of the tests — EKGs and ultrasounds for blocked carotid arteries — are among 130 procedures that a coalition of 19 physician organizations say are overused and should be questioned by both patients and their doctors.
False positives, or results that erroneously indicate disease, are more likely when screening broadly for a condition that affects only a small number of people.
Because narrowing of the carotid artery, a risk factor for stroke, affects only about 1 percent of people older than 65, the task force estimates that 4,348 people would need to be screened with both ultrasound and a follow-up magnetic resonance imaging test to prevent one stroke.
Area hospitals that do not participate in the HealthFair promotion provide more limited screenings for heart disease and stroke risk, and in most cases the tests are free.
Suburban Hospital in Bethesda, for example, offers free screenings for abnormal or diseased veins in the legs. After a quick visual exam, patients with potential problems might be referred for ultrasound tests, for which the patient would have to pay, said Andrew Schulick, a vascular surgeon. Suburban does not sponsor the screening packages offered by HealthFair or Life Line.
Schulick said that, in his opinion, screening the general population is not “achieving a whole lot in terms of improving community health, because you’re not going to find a lot of people” with problems. He said that anyone older than 60 with risk factors — such as hypertension, a history of smoking, diabetes, high cholesterol or a family history of peripheral arterial disease or stroke — are “the folks who ought to get screened.”
Shady Grove Adventist and Washington Adventist sponsor some tests that the U.S. Preventive Task Force recommends against as broad screening measures, including ultrasounds of the carotid arteries and checks for peripheral arterial disease.
The hospitals, part of Adventist HealthCare, say they offer the tests free at least twice a year and ask patients if they have any risk factors, including being older than 50, smoking and having diabetes, or high blood pressure or cholesterol, said Kathleen Coleman, Adventist’s cardiac and vascular outreach coordinator for health and wellness.
‘These tests don’t do harm’
HealthFair’s chief executive, Terry Diaz, said in an e-mail that early detection of risk factors for heart disease and stroke saves lives, and HealthFair’s data “clearly indicate that a large percentage of the asymptomatic population do, in fact have unknown disease processes forming.”
Of 220,000 tests the company performed in a recent nine-month period, 11.6 percent showed mildly abnormal results and another 2.1 percent had results at least moderately abnormal, according to data provided by the firm.
Diaz’s statement notes that many of the country’s almost 50 million uninsured people cannot afford regular health care. “HealthFair was created to fill this gap” by offering relatively low-cost testing packages and then partnering with hospitals to contact those with abnormal results, it says.
Diaz said the company, based in Winter Park, Fla., follows the recommendations of the American College of Cardiology Foundation and the American Heart Association on which patients should get screening tests. He added that while further study is needed to “truly determine the effectiveness of those tests in determining cardiovascular risk, the ACCF/AHA clearly supports the screenings that HealthFair performs.”
But the groups’ guidelines do not support routine screening of the general public with some of the tests HealthFair promotes.
John Gordon Harold, president of the American College of Cardiology, said in an e-mail that the guidelines from his group and the heart association do not endorse HealthFair or any other screening company. “Neither organization recommends broad screening or specific drugs, devices or companies in those guidelines,” he said.
Screening proponents acknowledge that serious problems are found in fewer than 1 percent of those tested, but they say the efforts are worthwhile because they spur important discussions between patients and doctors.
“These tests don’t do harm. People are not exposed to radiation,” said Johnna S. Reed, vice president of business development at Bon Secours St. Francis Health System in Greenville, S.C., which began doing screening programs with Life Line Screening a year ago. “I want people to have this information.”
Worried consumers sign up
Fear of stroke or heart attack is what draws many people, including Thomas White, 29, to screening programs. The Chantilly resident recently paid $350 for a package that includes the five basic tests, along with several others checking for risk factors for heart disease.
“I’ve had several co-workers who have had heart problems,” said White, who had the tests at an Inova/HealthFair bus parked in a Wal-Mart parking lot. “One of them died. I’m a family man, so I wanted to make sure I’m okay.”
White, who has no health insurance, said he would try to find a doctor to discuss the results. He admits that what he really needs to do is quit smoking.
Corrinne Naranjo, 66, of Centreville, said the tests were worth the time and money. “How many people are walking around with diabetes and don’t know they have it? Or heart problems?” she asked.
Several hospitals that have partnered with HealthFair or Lifeline have decided that the program is not worth their time or money.
Thomas Jefferson University Hospital in Philadelphia, for instance, is not renewing a year-long program, mainly because it uncovered too few health problems and resulted in only about 20 referrals of new patients, spokeswoman Lee-Ann Landis said.
HCA Virginia Health System in Richmond plans to end general community screenings, but it will offer the HealthFair testing to employers that request it, spokesman Mark Foust said. “We want all of our public screenings to be completely appropriate,” he said.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.