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CHECK-UPS PROPOSED BY HEALTH MINISTRY MIGHT NOT BE BEST WAY TO CATCH DISEASES

Prevention not always the cheapest measure

SPEECH check-ups for children and colonoscopies for senior citizens might be soon covered by public health insurance, once the Health Ministry adds these preventative examinations to the list of procedures that the state pays for.
Critics say prevention is important but they doubt the economic viability and the actual medical benefits of the new preventative check-ups the ministry has chosen.

SPEECH check-ups for children and colonoscopies for senior citizens might be soon covered by public health insurance, once the Health Ministry adds these preventative examinations to the list of procedures that the state pays for.

Critics say prevention is important but they doubt the economic viability and the actual medical benefits of the new preventative check-ups the ministry has chosen.

According to the Health Ministry's draft amendment to the law on the services covered by public health insurance, three- to five-year-old children would be entitled to a logopedic (speech) check-up to detect speech and pronunciation defects. Patients between 18 and 46 years old could undergo a breath test to detect Helicobacter pylori, a bacteria that can occasionally lead to peptic ulcers, gastritis and other infections, at a gastroenterologist's or general practitioner's once in their lifetime.

Also, patients over 50 years old would be entitled to a colonoscopy at a gastroenterologist's once every 10 years, in hopes of detecting stomach ulcers, colon cancer and rectal cancer at earlier stages, according to the draft.

"Because the Slovak government's health care programme emphasises prevention, early diagnosis of diseases, and support for important prevention programmes that benefit all of society, the law needs to be modified," reads the official Health Ministry document.

But the Health Ministry's proposal is not justified by either medical reasons or a cost-benefit analysis, Angelika Szalayová from the Health Policy Institute think-tank wrote in a report.

"Including any medical service into public insurance, and prevention is no exception, should be accompanied by an assessment of cost-effectiveness," Szalayová said. "The ministry has not submitted any analyses for any of the suggested check-ups."

According to findings of the Slovak Gastroenterological Society, 40 to 52 percent of Slovaks were infected with Helicobacter pylori in 2003, Szalayová said. The bacteria can infect the lining of the stomach and duodenum, but most people who have it will never get any disease.

When a patient has no symptoms, the helicobacter infection is not treated. And even when the infection is cured, it does not mean the patient will never get infected again.

"This is why screening for Helicobacter pylori is a useless procedure from the medical point of view," said Szalayová in her report. "If all the patients entitled to the test (about 2.5 million people) undertake it in the first year of the new legislation, the costs would amount to Sk5.9 billion (€174.8 million)."

The detection of Helicobacter pylori does not fit in with the current system and the proposal was probably not properly considered, Peter Lipták, president of Slovak Society of General Practice, told The Slovak Spectator.

"Since the ministry suggests everyone between 18 to 46 years of age should undertake the check-up, the scope is just too large," Lipták said. "A breath test is a very expensive method and it is done only at one place in Slovakia. It is more expensive than gastrofibroscopy, which is an examination used for detecting Helicobacter pylori when patients actually have problems.

"The breath test should be reserved only for people who feel pain when the gastrofibroscopy is done, as it is now," he said. "We cannot base prevention on such an expensive method."

For detecting stomach ulcers, colon cancer and rectal cancer, Slovak patients over 50 are currently entitled to a fecal occult blood test (testing for the presence of microscopic or invisible blood in the stool, or feces) once every 10 years within a general check-up at their general practitioner's. It is covered by public health insurance.

Slovakia and the Czech Republic have a good record of preventing these diseases with the existing occult blood test, on a higher level than the rest of Europe, according to Lipták.

"Only after a patient is positive in the occult blood test do we suggest colonoscopy," Lipták said. "If we want to adopt colonoscopy as our preventative measure, we should abolish the existing system. We cannot have both working simultaneously. The current number of gastroenterologists would not be sufficient. But why get rid of a system that works pretty well?"

"The ministry, instead of working out a cost analysis and comparing the two methods (colonoscopy and fecal occult blood test) and choosing the more advantageous one, suggested covering both examinations," Szalayová from Health Policy Institute said.

The Association of Health Insurers said the ministry should focus on raising citizens' awareness about preventative check-ups that are already covered by public health insurance, instead of suggesting new ones. The association does not think there are enough medical reasons to introduce check-ups in the three areas suggested by the Health Ministry.

"We should instead encourage people to use the prevention possibilities they already have," the association's executive director, Eduard Kováč, told The Slovak Spectator. "For example, citizens could keep doing what the law allows now and undertake a general preventative check-up every two years. This is quite efficient in revealing risks for many diseases. But a Slovak is disciplined only when he or his relative is already in danger."

A common myth says that prevention is the cheapest treatment because the cost of one preventative check-up is usually lower than the cost of treating one disease, said the Health Policy Institute report.

"This comparison is not correct, however," Szalayová said. "The reason is that a preventative check-up is usually done for a much larger group of people than the group of people who actually have a disease."

The price for the prevention is either appropriate or inappropriate, Szalayová said.

As all the benefits can be measured in financial terms, it is necessary to argue whether the cost-benefit ratio is acceptable.

This is a legitimate question for public discussion, which the ministry should also extend to the whole package of health care covered by public health insurance, she said.

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