It is a sad fact of American health care that state-of-the-art early disease detection tests and comprehensive preventive care are financially out of reach of many of the people who most need them.
Insurers, managed care plans, and federal programs seldom cover cutting edge detection tools, to say nothing of early preventive interventions, or a physician’s time spent discussing meaningful risk reduction lifestyles. As a result, most poor and middle-class people have limited access to the sort of care that could really help them live healthier lives and prevent premature deaths.
James Ehrlich, MD, a pioneer in the development of cutting-edge high-tech disease detection centers, hopes to change that with the establishment of the Identify Disease in Advance (IDA) Medical Foundation. The idea, he says, is “to democratize prevention.”
In 1996, Dr. Ehrlich founded the Colorado Heart & Body Imaging Center, Denver, one of the nation’s most technologically advanced screening centers. Over the years, clinicians there have identified thousands of individuals with early coronary disease and hundreds with very early stage cancers, using advanced imaging technologies and biomarkers. Most of these people were deemed “healthy” by their doctors.
The issue became very personal for Dr. Ehrlich, when his mother, Ida, unexpectedly developed a stage 3 lung cancer that presented as an episode of chest pain and pneumonia. “We had already developed an early lung cancer identification program in Denver, and we knew that if we find lung cancer in the usual way (symptoms or incidental mass on chest x-ray), the 5-year survival is only 15%. But if detected at stage 1 by high-resolution lung CT, or at stage 0 by sputum cytology, the survival is about 85%,” he told Holistic Primary Care.
“In 2002, at my mother’s eulogy, I promised to develop a nation-wide foundation to make these technologies available to those who could never afford them. I named it after my mother, because almost every family has an ‘Ida,’ a beloved person whose first manifestation of heart disease was heart attack or sudden death, whose first sign of cancer was a late sign like anemia, weight loss or pain.”
He noted that when he first got into the field of diagnostic imaging and early detection, he never expected it would become the domain of the wealthy. But because healthcare plans were reluctant to embrace new diagnostic techniques, that’s exactly what happened; the Colorado Heart & Body Imaging Center, “very quickly became the province of the well-off. They were impervious to managed care’s indifference or refusal to cover screening procedures. We had very few minority patients, though statistically they are at greatest risk for heart disease and cancer.”
Powerful Predictors, Painfully Underutilized
Dr. Ehrlich, who is also Chief Medical Officer at Atherotech, a company that provides the sophisticated VAP cholesterol test (www.atherotech.com), said many managed care plans actually discourage people from early risk assessment by resolutely dismissing techniques like electron beam CT (EBCT), arterial stiffness measurement, virtual colonoscopy and sleep apnea home-testing as “unproven and experimental,” despite reams of data validating them.
For example, EBCT calcium scanning is the only proven way to non-invasively detect non-obstructive coronary atherosclerosis, which accounts for the overwhelming majority of cardiac deaths each year. Statistically, it is “the most powerful predictor of heart attacks, bar none.” In 68% of all myocardial infarctions, the culprit lesion causes less than 50% vessel occlusion. These patients are usually asymptomatic and will pass all types of stress tests in the weeks prior to a devastating event.
“Many of these dangerous lesions could be detected long before they become fatal, because high coronary calcium is detectable years before CV events. We know there are ways of stabilizing these plaques and reducing inflammation. Yet most insurers discourage people from getting EBCT scans. People who want it must pay out of pocket,” Dr. Ehrlich told Holistic Primary Care in an interview.
Physical exams and risk factor profiles really are inadequate, he said, noting that 82% of women under age 70 who have heart attacks would be considered low risk by Framingham office-based criteria in the weeks prior. Many people are at higher risk than they—and their doctors—realize.
A host of new, well-validated risk assessment tools are now available, not only for CVD, but also for various cancers, autoimmune diseases and other serious conditions. But generally, only well-off people can afford them, and thereby avail themselves of the nutritional and lifestyle interventions that tend to have their biggest impact when diseases are in their earliest stages.
Despite the fact that the greatest burden of disease is among poor people, not those who can afford $10,000 executive physicals, preventive care has become “boutique” medicine. Valuable technologies are underutilized, and opportunities for prevention are lost.
Dr. Ehrlich believes this is a core defect in American health care. “All the money’s in acute care and most people must wait until they’re really sick to access state of the art techniques. You have to have a diagnosis code before you even quality for coverage of tests and services that might have prevented that diagnosis. But once you have angina, or you’ve had a first MI, then they’ll pay for everything.”
The Rationale for Hi-Tech Testing
One might argue that most of the risk for CVD and cancer is lifestyle and environment-related, and that high-tech testing is unnecessary if one is already working with patients to improve diet, strengthen cardiovascular and immune function, reduce stress, and eliminate environmental toxins.
It’s a reasonable line of thinking, but only on a population basis, said Dr. Ehrlich. On an individual level, it’s not always so easy to tell who is truly at risk.
“There is a big difference between using population-based guesswork to decide who is at risk, and precise, individual risk assessment, which can only be done with imaging and biomarkers. It is true that 97% of people who have a heart attack have an obvious risk factor. However, 96% of those who don’t get heart attacks also have those risk factors. The prevalence of these risk factors is so high that they do not really distinguish highest versus lowest actual risk.”
The same holds true for many cancers. The majority of colon cancers are in the “average risk” individual, whose sole conventional risk factor is being over 50 years of age. “We do screening tests because risk factors do a lousy job predicting cancer and heart disease in the individual, even though they show trends in large populations. Remember, [runner] Jim Fixx was low risk, yet died at age 51. Winston Churchill was high risk and died at 90.”
If IDA Known Better …
The principle behind the IDA Medical Foundation (www.idamedical.org) is simple: enable people with limited means to obtain tests at leading-edge diagnostic centers—which often have excess capacity—and underwrite the costs through charitable grants from families that have lost loved ones prematurely to preventable diseases that went undetected.
Dr. Ehrlich’s own Colorado Heart & Body Imaging center in Denver, as well as Heart Check clinics in Chicago, Los Angeles, and Washington, DC, will be among the first centers to offer CV risk screening to the IDA Foundation. Several other centers offering a range of early detection services are expected to join the Foundation by the time it goes operational early in 2009. Ultimately, Dr. Ehrlich expects to have 50 centers participating.
“The basic plan is to create 6–8 disease-specific programs in each city, with each one named after a loved one who died of that particular disease. The families, colleagues or employers will fund programs to cover the costs of providing tests to people who otherwise could not afford them,” explained Dr. Ehrlich. IDA will also ask donors to contribute a few hours each month to help raise awareness about these diseases and the value of early detection. “We’ll also go to large corporations and ask for donations to underwrite testing for their employees.”
The Foundation has already reached out to families of several prominent individuals who are agreeable to creating this type of legacy for their loved ones. IDA will also seek federal and state funding. For example, the federal government is sitting on a lot of money from tobacco industry settlements, a small fraction of which could subsidize early lung cancer risk screening for those at risk. “With a combination of new biomarkers, high-resolution, low-radiation CT, and spirometry, we’ve got a very good lung cancer risk surveillance protocol.”
The Foundation is also working with representatives from southern Colorado Indian tribal groups who are deeply concerned about the staggering diabetes and CVD rates in their communities. The groups have well over $4 billion in funds, mostly from casino revenue, some earmarked for health initiatives. Dr. Ehrlich is working with them to design tribal health programs named in honor of tribal leaders, to reduce risk in their most vulnerable people.
A Community-Based Endeavor
IDA is also reaching out to clinicians practicing near the participating diagnostic centers, to make them aware that they can send patients. “We want them to send well-off patients as well as those of limited income. We will ask the wealthier patients to make donations to the Foundation, if they can, and we’ll offer them tax deductions. We will provide the tests regardless of ability to pay, but we will ask people to pay what they can afford. It’s an honor system.”
Dr. Ehrlich told Holistic Primary Care that he relishes the idea of “telling rich people to get a virtual colonoscopy and a tax deduction at the same time, while knowing that they may also be saving someone else’s life by contributing to this non-profit foundation.”
Involvement of the primary care community is essential because early risk detection is meaningless if patients don’t have access to tools, knowledge, and guidance to reduce that risk.
“Patients coming into an IDA center must come through a doctor. This is both to pre-qualify patients—there’s no sense in doing an expensive, early CV risk profile in someone who’s already had a heart attack—but also so we can focus on courses of treatment. Referring doctors will get recommendations and protocols from us.” The tests provided through IDA can be used to create individually tailored comprehensive preventive programs.
“These tests routinely change management because they routinely re-classify risk. For example if a patient had a ‘normal’ regular cholesterol test, but a high level of Lp(a)—a very dangerous atherogenic particle—or had a calcium score of 200 when the typical score for his age is 10, we would advise the doctor to take a much more aggressive approach to risk factor modification than he or she might have done. The patient would more likely comply if he saw an actual picture of his heart. Improved compliance has already been proven after EBCT scanning.”
In the future, Dr. Ehrlich hopes to expand the palette of tests IDA can offer, among them, Sentinel Breast Thermography to identify women at risk for breast cancer long before tumors begin to form. “Thermography really looks into the future. And it doesn’t involve radiation, which is important because radiation is a very big deal especially in cancer-prone people. Women with BRCA gene mutations are extraordinarily sensitive to radiation. So if you’re doing mammograms on these women every year for 10 years, you’re increasing their cancer risk by 2–3%.” (For more on breast thermography, visit www.holisticprimarycare.net and read Breast Thermography: Can It Open a Window for Breast Cancer Prevention?)
Helping Patients, Helping Practices
Many imaging centers across the country are struggling because the equipment overhead is huge, maintenance and marketing costs are high, and each patient only comes for one or perhaps two visits. “All the other revenue is outsourced.”
Further, the state-of-the-art centers are often in direct competition with regional hospitals. “Many radiology departments at local hospitals have 64-slice, relatively slow scanners offering tests for $79–150. Top of the line EBCT scanners offer better accuracy with lower radiation, but they cost $395–495 per scan. The hospitals use the cheap scans as a loss leader to get patients in for stress tests and more invasive procedures that generate substantial downstream revenue. And insurers have to pay for them.”
“IDA will give doctors and their patients access to the best available technology. We want doctors to send all their patients, the rich ones as well as the poor ones. There is a bit of a Robin Hood strategy to it; we try to fund the care of the poor via contributions from the rich.”
Given Dr. Ehrlich’s role in imaging centers as well his executive position at a cutting-edge lipid testing company, one could argue that the IDA effort is self-serving. While it is true that part of the goal is to ensure the future viability of innovative centers offering state-of-the art techniques, the real aim is to put these technologies in the service of people who would really benefit from them but could never afford them.
“There will be inevitable claims by some that there are self-serving aspects of the program. However, the sheer variety of tests IDA will offer goes far beyond what Atherotech, or most imaging centers, are now doing. In addition, the centers in the past were for-profit. The non-profit nature of the IDA program allows these centers to continue their good work, rather than shutting down—which many of them are now doing. It will enable them to benefit a new population of people without a lot of money,” he explained.
“I believe we are addressing one of the distinctly immoral aspects of American health care: the fact that managed care ultimately determines which people in society get early detection.”
For more information about the IDA Medical Foundation visit www.idamedical.org, or contact Dr. Ehrlich via email at telemed@earthlink.net.
