American College of Physicians: Internal Medicine — Doctors for Adults ®

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When family history is a patient's chief complaint

Insurers need to take genetic predisposition to disease more seriously

From the September ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Arthur D. Silk, FACP

Fred Johnson is a 65-year-old recently retired salesman. Now that he has Medicare, he believes he is eligible for a level of medical care that he could never afford when he was self-employed.

Mr. Johnson's mother was diabetic, and his father and brother both met early ends from heart attacks. He wants to make sure that he does not suffer the same fate, so he thinks of seeing his friendly internist or family practitioner.

Unfortunately, Mr. Johnson lacks a major requirement for Medicare coverage: He has no chief complaint. In fact, he has no complaint at all. While he is wise in wanting to prevent a serious illness, Medicare does not cover examinations due to a family history of disease.

When Medicare came into being in 1965, the main worry of post-World War II Americans was the potentially ruinous costs associated with hospitalization and surgery. Medicare was intended to allay those concerns by paying the costs of catastrophic illness, hospitalization and surgery.

The federal government created Medicare specifically to cover services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." By 2001 standards of care, legal scholars could probably interpret this intent to cover Mr. Johnson's case. The government, however, has made a definite-and so far unchallenged-judgment not to. By definition, Medicare specifically excludes "preventive services or those benefits that are used to screen seemingly healthy patients for specific diseases."

In the decades since Medicare was introduced, we have come to realize the importance of treating patients for diseases they are likely to get because of heredity factors-before they become ill. Even Medicare has reluctantly agreed, although in a very limited sense.

Medicare, for example, now pays for Pap smears and mammograms in women who have no symptoms or no family history of uterine or breast disease. The program sanctions screening colonoscopies for patients who do not have a first-degree relative with colon cancer. Medicare even pays for screening PSAs in men who have no prostate symptoms or family history of cancer.

By what logic, however, can we justify screening for prostate cancer, a disease that will kill far fewer victims than heart attacks, while refusing to screen for dyslipidemia and coronary artery diseases? Where is the logic in paying for breast cancer screening while denying screening for heart attacks, which we know will kill eight times as many women? It is simply meshuge, Yiddish for what can be best described as mildly insane.

Medicine may have been different in 1964, but today we know with certainty that genetics bears heavily on the prognosis of progeny. The concept of "being born with good genes" has come into everyday parlance.

Insurers such as Medicare should consider the history of a parent or sibling with colon cancer as important to a history and a work-up as bloody diarrhea. When it comes to authorizing blood tests for diabetes, having a brother with diabetes should be considered just as significant as blurred vision. A father or an uncle with a history of a ruptured abdominal aortic aneurysm should be almost equivalent to a pulsating abdominal mass and a bruit.

And a history of a father who died at 52 from a myocardial infarction should be all Medicare or any insurance company needs to pay for a full cardiovascular disease work-up.

Dr. Silk is an internist in Garden Grove, Calif.

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