Friday, December 11, 2009

Ignore health reform scare stories

In a previous post, I argued that debates about the inclusion of a "public option" for health insurance in the reform bills taking shape in the U.S. Congress obscured the critical issue that elected officials have been reluctant to tackle: cost control. Extending insurance coverage to everyone is a moral imperative, but doing so will do little or nothing to hold down the rising price tag of health care, which is driven in large part by the proliferation of "care" that is unnecessary or harmful. In a New York Times editorial earlier this week, David Leonhardt observes that opponents of cost control use "scare stories" to falsely assert that cutting spending always means hurting patients:

Hospitals that practice more intensive medicine, to take one example, get no better results than more conservative hospitals, research shows. And while the insured receive better care and are healthier than the uninsured, the lavishly insured - those households with so-called Cadillac plans - are not better off than households with merely good insurance.

Yet every time Congress comes up with an idea for cuttting spending, the cry goes out: Patients will suffer! You're cutting bone, not fat!

How can this be? How can there be billions of dollars of general waste and no specific waste? There can't, of course. The only way to cut health care costs is to cut health care costs and, in the process, invite politically potent scare stories.

The trouble is, while disease advocacy groups such as the American Cancer Society can trot out endless legions of men whose lives have been "saved" by screening for prostate cancer, for example, you won't hear anything from the much larger numbers of men who have suffered permanent impotence or urinary incontinence due to surgery for prostate cancers that may never have affected their health. (A recent analysis in the Journal of the National Cancer Institute estimated that over 1 million additional men have been diagnosed and treated for prostate cancer in the U.S. since the introduction of PSA screening in 1986, and even under the most optimistic assumptions, only 1 in 20 of these men actually benefited from treatment.)

It's completely understandable that men who undergo treatment for cancer and suffer adverse effects from their treatment want very much to believe that their lives have been saved and that the harms they suffered were worth the cost. Doctors who detect and treat those cancers want to believe this too. In a phenomenon that has been called "a system without negative feedback," all of the incentives in U.S. health care conspire to encourage excessive testing and treatment for individual patients. Only by paying attention to health on the population level can we get a better perspective. Resources are limited, and given this fact, it makes no sense to squander resources on care that doesn't work, or care that hurts more people than it heals. Scare stories about cost control make for good headlines, but the story that scares me is what would happen if health reform passes without it.

2 comments:

  1. Excellent analysis.
    I would also point out that micromanaging the costs of the most-of-us who don't engender much of the cost of health care will be less effective than carefully looking at the benefit of the costs engendered on behalf of the few who cost a lot.

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  2. Let me share a brief story about one of probably many men who have suffered significantly from PSA testing. LJ is a 56 year old immigrant from Africa who was hospitalized briefy for kidney stones. While he was in the hospital, the doctors checked a PSA and it was slightly high. He had a biopsy which showed a low grade prostate cancer (Gleason 6). LJ was referred for surgery, where the cancer was sucessfully removed. However, as a result of the surgery, he suffered from erectile dysfunction. This would be difficult for any man to experience, but for LJ it was devastating, as just a few months before the surgery he was finally reunited with his wife of 30 years. They had been apart for 10 years while she awaited her visa to enter the US after a 10 year separation. Follow-ups with the urologist only led to frustration as ED meds did not work, but the doctor did not seem concerned as he had "cured" his cancer. However, for LJ he was now suffering far more than he could have imagined.

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