Map of life expectancy at birth from Global Education Project.

Monday, January 11, 2010

Okay then, that evil Cost Effectiveness Analysis

(Don't tell the teabaggers about this blog post, or they'll want to water the tree of liberty with my blood.) As I have emphasized many times, neither the legislation now before Congress, in any form, nor president Obama, proposes that the United States government support cost effectiveness analysis or use it to make or mandate decisions about spending by public or private insurance plans. As another reminder, it is true that the UK does use cost effectiveness analysis in its National Health Service, although mysteriously, Steven Hawking isn't dead.

So what is this evil Nazi procedure? First, remember that it is not, obviously, the sole goal of medicine to extend life. Health care aims to relieve symptoms and improve people's functioning, in other words improve our quality of life. So, if we want to somehow measure and compare the value of medical interventions, we have a difficulty: we need a common metric for quantity and quality of life. As we have seen, you can't just say that life is infinitely precious and therefore death is like checkmate: the king is infinitely valuable compared to all the other pieces. It just isn't so, whether we are talking about the cold fact that resources are not infinite, or people's moral intuitions.

The common metrics are called Quality Adjusted Life Years or Disability Adjusted Life Years. There are various approaches to calculating them. Probably the most common is simply to ask people how much lifespan they would give up to avoid certain consequences. And people are willing to make the trade – the answer is seldom zero. Averages from surveys of many people are used to come up with a number.

Another method is called the Standard Gamble: People are asked to think about a particular health state and then to consider whether they would prefer to remain in that health state for the next 10 yrs or take a chance with a hypothetical treatment. The treatment might return them to perfect health immediately, but might cause instant death. They are then guided to find the probability of cure vs. death at which they are indifferent about getting the treatment. Note that however you do this, and there are other ways, life is not infinitely precious to people.

However you calculate your QUALYs, the next step is to calculate the cost per QUALY gained by a given treatment. In the UK, an agency called the National Institute for Clinical and Health Excellence does this in an open and transparent way, with lay participation, and will generally not approve new treatments that do not deliver above a specified threshold of cost per QUALY, although there are exceptions. Note that this is absolutely not based on assessing the worth of any individual or any particular person’s remaining years of life. The judgment is applied to treatments, not to people. So no, they haven’t allowed Steven Hawking to die because his personal state of disability is irrelevant.

Nevertheless Americans have a very difficult time with this idea. For one thing, it seems to devalue the lives of people with disabilities or chronic diseases. Although we might think today that we would give up some life span to avoid disability, once we actually become disabled, except in extreme cases for some people, our lives do not suddenly become less valuable to us. I am completely sympathetic to that intuition, but it can be argued that it misses the point of how the QUALY concept is actually used. Nevertheless I agree that this is a complicated subject that requires open and respectful discussion. I have no dogmatic prescriptions of my own.

What we must remember, however, is that we already ration health care in the United States, we just do it in a completely indefensible and morally repugnant manner, by individual ability to pay. Right now, in the U.S. People decide every month whether to buy drugs, eat three meals a day, or heat their homes; are bankrupted by medical bills and lose their homes entirely; don't get basic medical care and end up with serious, expensive and completely preventable illnesses that the rest of us end up paying for.

Nevertheless, much of what we spend is wasted. We could actually spend less money and still eliminate this form of rationing.

And remember that even if the British National Health Service won’t pay for a treatment, people who have the money can still go out and buy it on their own. Nobody’s liberty is taken away, it’s just that society as a whole won’t pay for treatments that don’t deliver enough value for the money. So as far as having access to treatment, Britons today enjoy more liberty than we do, in spite of explicit rationing. It is ironic indeed that people who claim to be libertarians are precisely the people who are insisting that society as a whole is morally required to pay for medical treatment for individuals who cannot afford it, regardless of how high the cost and how modest the benefits may be. They obviously haven't even stopped to think for one second what they are actually claiming.

Next: the earth shattering conclusion, which you have already guessed.

1 comment:

clay barham said...

America was founded on individual liberty and local government no more than one day’s horseback ride from the governed. The 19th century Democrat was the staunch defender of state’s rights, which, under Federalists, Whigs and Republicans was assigned the role of slavery’s justifiers. The civil war cost us local government, the laws affecting behavior rising to the states and then the Federal government, way outside the one-day horseback distance rule that worked so well. The vigilante movements in the West and South were remnants of local home rule, where citizens concerned with the way they were governed took action to right the wrongs. The Tea Party Movement is another example of citizen participation against the governing elite centered far, far from the folks. It demonstrates the founding ideals of America are still the dominant tradition. The 20th century Democrats have declared war on Tea Parties as vigilantes and on America’s founding traditions, as cited in THE CHANGING FACE OF DEMOCRATS on