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M. Gregg Bloche, M.D., J.D. Headshot

Is it Rationing? Cancer Screening and Clinical Uncertainty

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Last month, the federal panel that decides which preventive services health plans must cover said it will drop blood testing for prostate cancer. The president of the trade group that represents urologists proclaimed himself and his organization "outraged." He warned that refusal to cover the test, for levels of prostate-specific antigen (PSA), will cost lives. And he played the race card, calling it "inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African-American men."

Others, including Newt Gingrich (at a presidential debate, after the panel released a draft of its PSA decision last fall) invoked "death panels," "rationing boards," and the like. But the panel, the U.S. Preventive Services Task Force, insists it doesn't consider cost. Its stated rationale for dropping the PSA test was simple and tragic. The test saves lives by enabling doctors to destroy or shrink tumors that would otherwise kill. But these lives are offset by harm done.

A positive test result triggers one or another invasive procedure to confirm or rule out cancer. Pain, bleeding, infection, and problems with urination commonly ensue. The wait for diagnostic results is anxiety-provoking for some, terrifying for others. Many of the cancers found are clinically insignificant: They'd go undiscovered without consequence absent a scary PSA result. Treatment, on the other hand, can lead to disabling urinary and sexual problems at least 20 percent of the time. On rare occasions, complications are catastrophic to the point of premature death.

Yet Task Force critics who claim "rationing" build on a grain of truth. A few studies suggest (without showing statistically) that men in their 50s and 60s may benefit from PSA screening. And it's true that African-American men are more than twice as likely as whites to die from prostate cancer. Individuals face dramatically different risks. And -- here's the rub -- our ability to offer personalized risk assessments is nil. We don't know enough to define subpopulations that differ in their chances of getting tumors that kill.

So, for some men, cutting out PSA screening is "rationing" -- if, by "rationing," we mean withholding of care that does more good than harm. For others, it saves not only money, but pain and suffering, and even lives.

The dilemma for PSA screening and many other tests and treatments is that there's no science-based way to know whether holding back constitutes "rationing" for particular patients. The biological variations between people are protean -- a consequence of the infinite combinations of genetic and environmental influence on human physiology. Clinical research can't possibly take account of all these variations. It requires large numbers of patients (to get statistically meaningful results). So it must pool patients who differ -- perhaps dramatically -- in their biological responses.

Thus, broad-brush clinical policies based on such research withhold beneficial, even lifesaving care to some while protecting others against harmful over-treatment. "Rationing," in other words, is inevitable even when clinical policymakers don't mean to count costs.

More robust rationing lies ahead, since we can't afford not to count costs. Health spending is on track to reach one-fourth of our Gross Domestic Product within 25 years. It's the main force behind ruinous long-term federal deficit projections, and it's eroding Americans' take-home pay and global competitiveness.

It'd be wonderful if we could simply cut out all the care that proves wasteful after the fact. There's broad agreement that up to 30 percent of health spending is to no avail -- a worthy target for cost-cutters. We can and should try to identify useless care before it's prescribed. But biological variation makes doing so difficult. The goal of eliminating the before-the-fact uncertainty that enshrouds useless care will remain beyond our reach for the foreseeable future.

So slowing the growth of health spending will require us to ration care -- if, by "rationing," we mean refusing to cover tests and treatments that extend or improve some people's lives. Both political parties now tacitly acknowledge this. Congressional Republicans and their presumed presidential nominee, Mitt Romney, urge a voucher scheme that would cap Medicare costs, giving private health plans the job of setting limits (and withholding beneficial care to keep within budget). President Obama and most Democrats back the Affordable Care Act's "Independent Payment Advisory Board," which will set similar limits by lowering Medicare payments.

The parties' rival approaches to controlling the costs of private coverage would likewise put top-down pressure on health plans to limit beneficial care. More price competition between insurers (urged by all), repeal of minimum coverage rules (pressed by Republicans), and tighter regulation of premiums (urged by Democrats) are among the strategies that would achieve this.

Both parties allege "rationing" (by the other), and both are right: These approaches will reduce access to care that prolongs and betters people's lives. Whether Americans will tolerate these limits is a grand question -- one whose answer will transform our economic future, for better or for worse. We're having trouble paying for all that medicine can now offer, and we won't be able to afford all that it will be able to do in the future.

It's past time for our politicians to tell us this, rather than using the "R word" as an epithet against each other. And it's past time for us to accept that we'll need to make painful choices between health care and our other wants and needs.

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