Speaker 1: It's great to welcome to the program today, David Liss, who is a health services
researcher at Northwestern University. He conducts research to improve the quality
and value of primary care delivery. David, it's great having you on today. Thanks for having me.
So, you know, in the context of Obamacare, but also more generally, there's the discussion of of
preventive health care, the idea that it's cheaper to prevent or treat something early than it is to
wait until it becomes more serious. I think that intuitively makes sense, too, to a lot of people.
But that can take sort of a lot of different forms and shapes. One can be you go into the doctor
every year and they feel around, listen to your lungs, et cetera. That could include doing regular
blood work, cholesterol, complete blood count, et cetera. Then there's also other types of screening
starting to do PSA and prostate exams for men at certain ages, colonoscopies, mammograms, etc. So
there's all this different stuff. How can we start to kind of categorize these things and think about
the impact on people's people's health from them? Speaker 4: Well, I think well, at least what
we do here in the research world or in those sort of medical care world is that there's an
organization called the U.S. Preventive Services Task Force, and that's been around for a while.
And but what the Affordable Care Act did is that it took services that are recommended by this
group, the USPSTF, as we call it, and services that are recommended by the by this group are now
fully covered under pretty much all or certainly most insurance plans that people have. So we're
talking about some of the things you mentioned. There are things like colonoscopies and colorectal
cancer screening mammography for women age 50 to 74 recommended vaccinations, et cetera. So there
are many services that have been shown. There's clear benefit that can help people live longer,
healthier lives. And there has been this group of researchers who has really sifted through the
data continues to pore through it every two years, and they find that these are beneficial services.
Other things like prostate cancer screening that I think you may have mentioned PSA test,
even these kind of routine lab tests. A lot of those services aren't actually recommended
to be done regularly, maybe for some high risk patients, but for your average or low
risk patients. Some of those services are not recommended by this group and aren't necessarily
covered for free through your insurance plans. Speaker 1: Yes. So you know, there's this idea of
what is it that we're trying to do like with a general health check. And one answer would be,
well, we're trying to diagnose something earlier in order to control it. And then a subsequent
question, I guess, would be OK if we do that, are we improving quality of life or extending life?
And I guess the answer is not always yes. It kind of depends on what we're doing, right?
Speaker 4: It depends, yes. But again, there are a lot of kinds of screenings we can do, a lot
of kinds of risk factor checks that can be done where again, if you catch it early and there are
available well known treatments, you can certainly be extending life and quality of life. Now the
problem there is that there, if you're doing things that aren't necessarily recommended,
maybe again, that could fall in the range of things like PSA tests could be things like
routine labs. There is a potential for a lot of these false positives as you walk, maybe the test
find something and it's potentially worrisome and leads to this sort of cascade of testing lots of
worry on the part of the patient. Additional testing, and sometimes all for no reason,
offer sometimes for false positive mammography that happens sometimes. So what we what we try
to do sort of in the research world, the medical world is find a balance between whether three,
as we've heard, I think sometimes when we think about the vaccination debate for COVID, where do
the potential benefits outweigh the potential harms? And again, there are several services,
certainly colorectal cancer screening being one where the potential benefits certainly
clearly outweigh the potential harms. One of the Speaker 1: things I read, and I'd be interested in
hearing what your research has shown are your take on it is that a lot of the things that are done
that are kind of in the cardiovascular under the cardiovascular umbrella
don't seem to actually reduce an individual's chance of having a heart attack. What
is? Can you talk about that a little bit? Is that
true? What does it even mean to say that? Speaker 4: Well, what I what I certainly
can say is that some of the bread and butter things we think about most,
most stereotypically checking your blood pressure know obviously that all of our Typekit that's
perhaps the most are certainly one of the most important things that can happen in terms of
helping people identify a health problem and getting it under control. Many highly effective,
inexpensive treatments that can help prevent heart attack, stroke, death, et cetera. Some
of these other, maybe more exotic kind of tests again, doing a lot of digging, doing a lot of
tests that aren't necessarily recommended. Again, that's what we're talking about. The potential
harm could outweigh the potential benefit. Speaker 1: When we talk about the annual
physical for a second and we have the parts which are a discussion where you might mention symptoms
or answer lifestyle questions, and then you have the physical exam, which, depending on one's age,
varies and then you have here are the blood tests or other things that I want you to do
everything. But the physical exam could be done virtually. What do we know about the what do we
know about the importance of the part that's happening in person with the annual physical
versus the other? And of course, once you're at a certain age and there's a, you know, a prostate
check that obviously cannot be done virtually. Speaker 4: So you're right. A lot of these sort
of elements of these visits could be done virtually. What I would also say
is that what some of our research has shown Richard's research really clearly shows is that
the physical exam is a comprehensive physical is not necessary. Hmm.
What has been shown to be clearly effective and I think you alluded to there is we're talking
about lots of screenings, lots of risk factor checks. And again, as you said, a lot of that
could be done virtually could be done even on, you know, can sometimes be a questionnaire on your
computer. Things like screening for depression, screening for problem drinking, screening
for smoking or tobacco use. So much of this, these kind of screenings can be done virtually.
What were the I think what's interesting, what we'd like to learn is what can be done really
well virtually. What are some good models to do that virtually? Certainly, there's a lot of
work that can be done, but let's say you do find a patient is depressed. Now, if you've done that
screening virtually, how can you connect with them and get them in to get recommended care
or and or, you know, things like blood pressure screenings, if someone's experience that it
certainly they could be doing it if they have one of these blood pressure cuffs, that could be that
could be used at home. That said, it's not always so simple, and I think it'll be really interesting
to see what are the balance. What what can we clearly find that can be done well consistently
at home or virtually versus what things need to be done in office? And how do we sort of
get that sort of division of labor worked out? Speaker 1: One of the things that seems like it
might make it more difficult to ascertain sort of health outcomes and health status might be
that people who do the annual physicals, maybe folks that are already more likely to maybe make
healthier lifestyle choices or maybe eat a better diet or whatever the case may be. Is it possible
to separate that out to really talk about the impact just of the physical and the screenings?
Speaker 4: So there's a I think maybe a couple of things you mentioned there, let me again go first,
go back and say these physical exams themselves, we don't really need these comprehensive physical
exams yet, as you said, John, as well, these visits these check ups, as I like to call
them. Oftentimes what we find is that people who are most likely to get these checkup visits are
people who have gotten them previously right. For that group, we found the potential benefit isn't
as great as people who might be sort of height from higher risk groups. And for those folks who
aren't necessarily as motivated, I would certainly encourage them to sort of think about getting one
of these checkups. But from a from the perspective of a health care system or a health system,
that's where we need to do a little bit better work in terms of identifying those patients
and finding ways to get them and finding ways to help them understand the need to come in and the
benefits for coming in. Or if it doesn't involve coming and doing some sort of a virtual screening,
meeting them where they are and doing one of these checkups, because that's where
a really checkup visits have you think, have the most value people who haven't necessarily
been well connected with the doctor who might be overdue for preventive services, whether
that's cancer screenings, vaccinations, etc. Speaker 1: It's often mentioned that there are
people who believe that the reason that a lot of these things are suggested, etc. is a desire from
medical practitioners to avoid lawsuits to say, Hey, listen, I did my part, I did everything I'm
supposed to do. We're going to add stuff, and the more stuff we add, the more likely it is. I can
say I didn't commit malpractise. I did everything I was supposed to do. In your experience,
how valid is that concern or that assertion about the entire preventive care world?
Speaker 4: Certainly not. I would certainly not agree with that as it relates to the
entire preventive care world because as we spoke about a couple of minutes ago,
when we talk about for what most insurance plans are going to cover with zero co-pay for
patients as a result of the Affordable Care Act, we're talking about these high value recommended
services that have been screened and are in our reviewed every few years by this panel of experts.
And these are shown to be consistently high value services. Now that's there is that we
need to strike that balance. We don't where I come out and I say we want people to come in for
checkups and get some of these recommended high value services. Where it's good is that again,
they're covered with zero co-pay. Most people are not going to have to spend a dime to be getting
these services that their checkups, their cancer screenings, their vaccinations, screening for
depression, et cetera. Some of those lower value services, some of the things that people, as you
mentioned, might be sort of more skeptical wolf. I think some of those things, there is a reasonable
skepticism and some of those things the experts have shown there isn't good value to those. But
for the typical checkup covered by your typical insurance company,
we're talking about high value services that have been shown to be effective and again aren't going
to cost people money to be receiving them. Speaker 1: Related to this, and I don't know
if you can say anything about this at all, and if not, that's fine. When we talk about the dental
cleaning and now we're talking about dental health number one, there's research into the connection
between dental, health and general health, which seems to be pretty compelling. And number two,
it seems that in that case, we're really talking about something with very specific benefits,
where in all of this does the dental cleaning every six months and with or without X-rays, which
I know is a big source of controversy for some? Speaker 4: Yeah, I I don't have much expertize
there. So and my research doesn't really focus on dental cleaning that much. But as you said,
I've heard that there's a lot of research showing that dental cleanings are associated. I believe
with good kind of cardiovascular and heart health outcomes, which is quite interesting,
probably relates to some issues as it deals with things like inflammation in the body, right?
But also maybe speaks to the fact a little bit of how sort of siloed sometimes health
care is in the United States and that a lot of us health insurance coverage is separate from dental
coverage. And those aren't maybe necessarily as sort of harmonized or as comprehensive as
they should be in the dental care area. But again, regular checkups sound I know is a
is something that is recommended for dental care, and it has been shown to
be associated with good overall health outcomes. Speaker 1: A very, very interesting. We've been
speaking with David Liss, who's a health services researcher at Northwestern University. He conducts
research to improve the quality and value of primary care delivery. Really appreciate your
time and sharing your insights, David. Speaker 4: Thank you. It's a pleasure.