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The Problem Isn't the Recommendation, It's How We React to It.

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In case
you’ve been under a rock, last week the U.S. Preventive Services Task
Force
released their updated recommendations on screening for breast
cancer.  The USPSTF is not a political
organization.  They aren’t an advocacy
organization, or even a policy making organization.  They are, “[a]n independent panel
of experts in primary care and prevention that systematically reviews the
evidence of effectiveness and develops recommendations for clinical preventive
services.”

Here’s what
they said:

The USPSTF recommends against routine
screening mammography in women aged 40 to 49 years. The decision to start
regular, biennial screening mammography before the age of 50 years should be an
individual one and take patient context into account, including the patient's
values regarding specific benefits and harms.

Right below
that recommendation appears this quotation from Diana Petitti, Vice Chair, U.S.
Preventive Services Task Force, in a highlighted box:

"So, what does this mean if you
are a woman in your 40s? You should talk to your doctor and make an informed
decision about whether a mammography is right for you based on your family
history, general health, and personal values."

Mammograms
weren’t outlawed.  They weren’t taken
away.  No one’s insurance stopped
covering them.  This was a reasoned
statement that because the evidence suggests that universal screening of women in their
40s may not be doing more benefit than harm, each woman should make an individual decision with their physician. 
It was based on a transparent analysis that anyone could repeat.  Read the full report

But – to be
honest – I don’t want to have a discussion about mammograms.  It’s not my area of expertise, nor an area in
which I feel especially qualified to tell you what to do.  I suppose that makes me rare.  But I am reasonably
knowledgeable
about decision analysis and how these studies are done.  

Although
many seem to hate comparative effectiveness research, or cost-effectiveness
research, or whatever you want to call it, those same people often seem obsessed
with the cost of reform.  Yet the cost of
reform (maybe $90 billion a year) is NOTHING compared to the cost of health
care itself ($2.5 trillion, or $2500 billion a year).  The first question I am always asked is, “Why
does care cost so much in the United States?” 
The simple answer is because everything costs too much.  Look at this graphic from a McKinsey
Global Institute study
of healthcare:

 

2009-12-01-McKinsey_Healthcare.jpg

Yes, it’s a
bit overwhelming, but here’s the critical part. 
The dark blue bars are the amount that the US spends which is more than you’d expect for what we get
in return.  We like to demonize the
private insurance industry, and the “wasteful” spending there is more than 60%
of all spending on health administration and insurance, but it’s only a tiny
percentage of overall spending.  Same
goes for drugs, where "wasteful" spending is less than $100 billion.

"Wasteful"
spending in outpatient care, however, is over $430 billion a year.  Know what
that includes?  Doctors.  Hospitals.  Nurses.  Actual
things patients want, like office visits and tests (even mammograms). 
There’s actually two and a half times more "wasteful" spending in actual care
than in drugs and health insurance combined.  But it’s very hard, and
politically unpopular, for us to attack those providing care.  So we focus
on other things, facets of the system that contribute much less to the overall
cost.

But if we
aren’t willing to tackle wasted care, we will never truly contain costs. 

How can we
decide what works and what doesn’t?  How
can we decide what can be cut?  That’s why we need comparative
effectiveness research.  That’s why we
need bodies like the USPSTF.  Independent
organizations made up of people who understand the research and can inform us
how some things compare to others.  They're not perfect, but they are transparent, accountable, and public.

We so often
act as if everything in medicine is an unequivocal benefit.  That’s simply not the case.  Everything has harms as well.  Ideally, the benefits outweigh the
harms.  Sometimes, however, that’s not
the case.  And sometimes, in the real
world, cost is a harm.

There simply isn’t an unlimited amount of money in the budget.  Each dollar we spend on stuff
that doesn’t work is a dollar we can’t spend on stuff that does.  Legitimate care is denied every day.  Ideally, it should be denied when it doesn’t
work, or isn’t providing bang for the buck.

How are we
to prioritize what to pay for?  That’s an
excellent question.  I don’t necessarily
have the answer.  But we need to find an answer.  Putting our heads in the sand and pretending
that we will never need to make these decisions will result in economic
ruin.  Saying that we need to cut costs
and then declaring that any attempt to find places we can cut costs is rationing – sometimes even saying those
two statements almost simultaneously – is not only hypocritical, it’s also
dangerous.

And that’s
why this last week has been so disappointing to me.  Research isn’t perfect, not even that done by
the USPSTF.  But instead of having a
debate about the merits of the findings of the USPSTF, we were flooded with
politics.  On day one, we were all
confronted with this:

“Tens of thousands of lives are being saved by
mammography screening, and these idiots want to do away with it,” said Daniel
B. Kopans, a radiology professor at Harvard Medical School. “It’s crazy —
unethical, really.”

This kind of
rhetoric, calling the USPSTF “crazy” and “unethical” does nothing to move the
debate.  The “numbers of lives saved” are
also not based on research.

Understand –
most of the “waste” in health care comes from just this sort of stuff.  It’s not easy to identify, and even harder to
cut.  It won’t be universally popular,
and it won’t win anyone political acclaim. 
But it needs to be discussed and debated. Someone is always going to be
upset at cuts in spending.  They can’t
come from nothing. 

If we’re not
willing even to entertain a discussion of cuts, though, we’re doomed.  If we declare any recommendation to reduce
expenditures as "rationing" or "unethical", then we will go bankrupt.  We need leaders willing to host a rational
discussion on health care costs free from partisan rhetoric, or we might as
well close up shop now.

 

Read more about health care policy and get your
questions answered at
Rational Arguments.