Health Care thoughts: Comparative Effectiveness Research, Gender and Emotion
by Tom aka Rusty Rustbelt
Health Care: Comparative Effectiveness Research, Gender and Emotion
A key cost bending feature of PPACA (Obamacare) is comparative effectiveness research (see http://www.hhs.gov/recovery/programs/cer/index.html).
This research is designed to apply statistical, economic and clinical analysis to care and treatment to encourage effective care and block ineffective treatments.
It is highly likely, based on current research, the statisticians will recommend less screening and much less treatment for prostate cancer. As my doc says, “almost all old men die with prostate cancer, almost none of them die from prostate cancer.” Screening should likely be focused on younger men and more aggressive forms of the cancer.
With men being somewhat nonchalant about such matters, and prostate cancer being something less than a celebrity telethon issue, it is unlikely there will much of a fuss. Money can be saved and the resulting increased mortality will be slight.
At the same time, current recommendations about breast cancer are suggesting a lot less mammography, and there is an uproar.
(I must plead guilty to being protective and emotional, Mrs. R. will have annual mammography, despite a clean history and no risk factors, if I have to pay out of my own pocket.)
Breast cancer hits many women, hits many younger women, and the results are horrifying. The blowback from advocacy groups has been and will be fierce.
So can we get past gender and emotion to become more efficient and effective? I doubt it, and readily admit I am one of the culprits.
you have put your finger on the heart of the problem.
i know a lady who was treated for breast cancer. there is considerable doubt as to whether she ever actually had breast cancer, but now she is part of the statistics for “cured” and “the value of early recognition.”
maybe. maybe not.
but who is going to tell you “don’t bother” when to you it is your wife’s life on the line. even if they tell you there is more risk from the mammogram than from any likelihood of cancer.
so at the end of the day we will be paying our entire incomes to doctors to save us from dying.
and that will more likely be the case when “the government pays” than when we pay for it ourselves. not because we are any smarter than the government, or any more careful buyers of health care, but just that as individuals we tend not to get around to it.
i have made my own decisions. so far so good. i don’t mind paying for “everyone’s” health care, but at some point i am going to resent paying for the high standard of living of the chalatans who live off the fears of hypochondriacs and ordinary people who would like to live and don’t know what to think.
of course it could go the other way.
once “the government” is paying for it, it will have to compete for “federal dollars” with new blue submarines for the war on terror. then, i fear, you will be told that mammograms are not cost effective, because the women who die from breast cancer weren’t major contributors to the economy at the time of their death.
don’t get me wrong. i tend to believe the only possible way to pay for health care rationally is through a single payer. though i like the idea of the government acting in the current role of the “the employer” that is let the existing insurance companies bid for the actual business, but with a player on the other side of the table who can bargain realistically… and then, not the current model, oversee the contracts for honest delivry and potential cost savings.
just that given the politics, i don’t see it turning out like that.
“Money can be saved and the resulting increased mortality will be slight.”
Any increase in a mortality rate is defined as slight only by those not included in that increased mortality, and those that are a part of the increase will not think the savings worthwhile. However, the latter group will not have much of a voice for complaint.
If only the things of war were justified by statistics, economic and operational analysis to justify organizations and equipment and prepare efficient tactics for effective operations and refrain from deploying too costly, late and non performing jobs projects for the military industrial complex profit.
Wyrd Bid ful Araed
Absolutely. Can we divert some of the money to cut mortality elsewhere?
But how do you do the tradeoffs when society (insurance) is paying the bill? We can make safer cars, for example mandatory breathalizers on all cars, but society does not think the price is worth it. We could ban skydiving and save lives but again decide the tradeoff is not worth it. Look at the arguement over motorcycle and bicycle helmets.
At some point the issue becomes is spending this money when integrated over the whole population the most effective use of the resource? Individuals can pay themselves, and I suspect if insurance stops paying for this, screenings at greatly reduced prices will come about. (Look at lab tests screening costs are 1/5 or less of the full price of the lab tests)
A long time ago, mid ’80s, the FAA did a study to generate the value of a human life so they could do cost-benefit analysis on improvements to the aviation system. They used data from court cases on aircraft crashes (primarily) as the bases in finding this value. I still remember the number – $2.3 million. That was what the FAA analysts used for the baseline value. So if something cast $100 million but only saved one life – canceled. If the improvement saved 50 lives – go fot it!
This is exactly the cost-benefit analysis we are going to see in Obamacare going forward. If your rich – no problem – you pay out of pocket for the mamogram or whatever. If not you accept the ‘slightly’ increased mortality.
And if you think politics will not have a thumb oon the scales your nuts.
Islam will change
DHHS will mandate what is acceptable health care and what is not; insurers will be expected to follow and providers will face the economic consequences. Some people will find ways around the system as you suggest, and some providers will find novel ways to adjust.
If done properly we would just good quality health care with a lot less waste. And we trust the government because……
Well you know prostate cancer is sort of a hot button with me because my maternal grandfather died of it at 58 which I turned in July. At the same time, a guy I swim with had a routine employment physical at age 48 which included a pSA which was 25. They removed his prostate after radiation and he went through a couple of rounds of chemo, but the prognosis is not good. It has almost certainly micr metastized to his bones and all they can do is keep trying to keep it at bay until someone comes up with an effective treatment. It is hard to look him in the eye when I ask how he is doing. Of course if he had routine physicals they would have found it much earlier and he would have all the problems associated with treating prostate cancer, but he would not be dying from it. I guess I think that inexpensive and relatively non invasive screening is warranted, but if questions turn up physicians are always going to recommend further procedures not necessarily out of greed, but in order to cover their butts from malpractice.
Always there whether a revenoor or the Boss.
There is one school of thought that PSAs should start earlier but then be discontinued at some age (70?), because younger people seem to get the more virulent cancers.
If any of you guys have not had a PSA recently and are 40 – 70 it is time for sure.
From another perspective, increasiong the acceptable level of mortality inorder to save on the costs of prevention and early detection may be the way to improve our employment numbers. Fewer survivors will result in greater job availability.
Do executive fringe pkgs get better detection and prevention coverages?
basically because we have no choice.
no consumer knows as much as the provider. the government is in a position to know as much. but that doesn’t mean it will always be right, and i am rather raspy about surrendering my choices to “experts.” what i’d think is an “acceptable compromise” is a government plan that pays for “cost effective treatment.” and if you think you need better than that you are free to buy additional coverage, but not to opt out of the basic group insurance plan.
Discontinuing at age 70 is derived from evidence that the cancer is slow enough that you will die of other causes before the cancer as well.
Modify that to pay for additional coverage or pay directly. So for example if a mamogram you paid for is positive the insurance pays for the treatment. The bigger question comes up with some new drugs that cost a couple of hundred thousand for a couple of months longer life. Should society pay for this, or not? Or should there be a max age for transplants? All are serious ethical issues, but do need to be considered as there is no such thing as a free lunch (Heinlein) even with insurance.
How else do you ration healthcare? There is an unlimited demand and a limited supply of this service. One can use the market and ration by wealth, which is more or less the present system, the bottom and the top get care but folks in the upper lower area get denied. One has to decide for example if a drug that give 2 more months of life for 200,000 is worth it. This is of course in terms of insurance or society paying for the care if you have sufficient resources you can get it if need be outside the us. (Europe and Singapore are likley as good a medical place as the US).
The engineering logic is just cost benefit analysis, to place a to high value on a life means society spends more on health care so there is less to spend elsewhere. Insurance companies do this to some extent today as well.
Of course on screening if insurance stops paying then programs will come back at real cost to do the screenings. For example consider that it seems to take 2 months for medical bills to get paid due to the system, if some screenings are done cash on the barrel head it can be cheaper.
i suspect the “ethics” would change when it became a common enough choice that most people felt it in their pocketbooks.
i don’t understand your example about the mamogram. the insurance company (US) may not want to pay for routine mamograms, but i cannot imagine an insurance policy that would refuse to pay for cancer treatment discovered by an exam the customer pays for out of pocket. not that a private company wouldn’t want to deny coverage, but that no sane person would buy such a policy.
i imagine that in the two months for 200,000 dollar case, you could buy an insurance plan “with” or a plan “without”. or the government plan would be “without” and you could buy extra coverage “with.”
the problem would come when all the peole who paid for “without” realized they had made a mistake.
then they’d want ‘welfare’ to cover it. and there’s be a huge outcry in the newspapers.
Perhaps I was unclear I meant what you said more clearly if a screening detected a problem the insurance would pay for the treatment.
I think we need high volume mammogram and MRI factories running 24X7 so we most effectively amortize the capital cost of pricey medical testing equipment. Then someone needs to be a specialist in interpreting the results, but I believe that if you build it they will come. At least in this case.
I also use a money saving technique with more routine blood tests. There are labs nationwide where you can walk in and order blood work, ranging from $60 for a normal battery of tests up to to $200 for the deluxe package. Then you can learn to read the test results yourself, or take them into your doctor if you want. This keeps doctors, clinics and hospitals from charging off all their ridiculous overhead onto tests they order from the same place on my behalf.