Map of life expectancy at birth from Global Education Project.

Monday, June 29, 2009

They're all wasted

Ari Hoffman and Steven Pearson, in Health Affairs, provide highlights of medical waste, by which they don't mean used needles, surgical sponges and ascending colons, but rather squandered resources. Distinguishing among the different kinds of waste is important to the political "discussion" we're having right now. The scare quotes are because it's mostly people in separate booths yelling past each other, with facts and logic often in short supply.

First, there's the kind they mention in passing but do not discuss, "excessive administrative costs, misused and wasted materiel, and inefficiencies such as duplicate testing and unnecessary physician visits generated by uncoordinated care." They say nothing further about this, but I will tell you right now that there is a simple, elegant solution that can eliminate almost all of this and has already done so just a a few feet away from Detroit: universal, comprehensive, single payer, national health care. But I digress.

Hoffman and Pearson are actually concerned about the kinds of waste Barack Obama is talking about when he discusses comparative effectiveness research, and Republicans are defending as essential to our freedom: medical interventions that might not be worth it but happen anyway. The subtlety is that they aren't all created equal. H&P identify 4 kinds of questionable interventions:

  1. Inadequate evidence of comparative net benefit for any indication;

  2. Use beyond boundaries of established net benefit;

  3. Higher cost when established benefit is comparable to other options; and

  4. Relatively high cost for incremental benefit compared to other options.

As to the first item on the list, it may surprise you to know that a lot of the drugs and medical devices that are widely sold, and surgical procedures that are commonly used, lack any scientific evidence for effectiveness whatsoever. Surgical procedures do not require FDA approval nor any evidence of benefit for doctors to use them, and medical devices can win approval on very flimsy evidence. But even drugs can be approved based on short-term comparison with placebos. They don't have to show that they are better than existing, cheaper drugs, nor that they provide any long-term benefit. That's just plain dumb, and the only reason we have that policy is so that drug companies can get patents on drugs for which there are cheap generic alternatives, without having to prove that their patented drugs are better, and then spend money on TV advertising and efforts to influence doctors so that the more expensive, and quite possibly worse, but new and exciting, drug gets prescribed.

The second item reflects a quirk in the law. Once a drug or device has FDA approval, doctors can prescribe or use it for any purpose whatsoever, which is called "off-label" prescribing. Companies aren't supposed to market drugs for off-label uses, but they do it anyway. Sometimes, the fines are just a worthwhile cost of doing business; more often the companies just get away with it because of lax enforcement.

While we might imagine that most people would readily agree that these practices ought to be curtailed, physicians as a class are against greater restrictions. They tend to see this as a question of professional autonomy and the right to exercise their clinical judgment, which they believe is more powerful than scientific evidence. Many consumers, I must admit, feel the same way. They flock to the GNC and buy mass quantities of stuff for which there is even less evidence of usefulness than there is for SSRIs -- and that's saying something. They trust decision rules (what we eggheads call heuristics) which are different from the ones used in clinical trials, and they expect their doctors to do the same.

The third and fourth categories are rather different. We know the stuff works, but either it costs more than something else that probably works almost as well, or it costs a huge amount and delivers what most people would consider a very small benefit. An example of the latter is paying tens of thousands of dollars for chemotherapy that can be expected to extend the life of a person with cancer by a few weeks. These are the kinds of issues that come up in the UK from time to time when the National Health Service refuses a treatment to some desperate person, and this is where the "rationing" rubber really hits the road.

If we could cut through the mass media tornado of trash talk and have a reasoned discussion, I expect most people would agree that we ought to try to have the best possible evidence for what works best under what circumstances, and we ought to stop mucking around with our bodies in ways that don't actually make us better, might make us worse, and cost a lot -- our God-given right to make choices that bankrupt and harm us is probably secondary, notwithstanding Betsey McAughey, John Stossel and Sam Brownback.

However, when it comes to the question of how much is worth spending to maybe benefit a sick person a little bit, the conversation does admittedly get more difficult. People have a glib reaction that "you can't put a value on human life" and the idea of accountants deciding that some necessarily largely arbitrary amount -- whether it be $10,000 or $50,000 or $10 million -- is too much to spend to "save a person's life" just doesn't sit right. The response ought to be obvious, but for some reason I can't quite grasp it is not to many people.

Note first of all that it is the very same people who are decrying the prospect of "rationing," in many instances, who are also insisting that we cannot afford the cost of providing universal health care. It is also very likely to be the same people who are opposed to environmental regulation, workplace safe and healthy regulation, and social welfare programs because they are "too expensive." We can't afford the economic cost of clean air, but it would be immoral to "ration" health care. These are positions which conservatives hold simultaneously, unapologetically, and apparently completely unaware of any contradiction.


Get Off My Back said...

Well written and well thought through, but I for one object to the so-called "reform" (which I've dubbed "deform") of health care not on the grounds that we can't afford it, but because it's all a sham to buy votes (and control of peole's lives) for the Democrats. Of course, there will have to be widespread, wholesale rationing down the road, probably right after the election of 2012 and passage of the 28th amendment to make Obama eligible to be president for life. The Democrats should come clean and own up to what they're doing in following the Lenin playbook. Quote V.I.: "Health care is the linchpin of collectivization."

Get Off My Back said...

Oops..."peole's" should be "people's" but "peons" would also work. (I knew I should've previewed the comment before publishing it.)