Map of life expectancy at birth from Global Education Project.

Wednesday, February 04, 2009

Preventing our way out of bankruptcy?

Health care reform has been pushed to the back of the room while all wait to get stimulated, but it's still on the program here. As I have mentioned from time to time, there is no serious cost containment in any of the proposals coming from the Obama administration or congress right now. The president (and it is at least a relief to be able to type that word without pain) has said that more emphasis on prevention can save health care spending, but is that really true?

Steven Woolf in the new JAMA reviews the issue. Unfortunately it's subscription only, but I largely agree with him and I can summarize it more quickly for you anyway.

If we spend money on preventing illness, we might end up saving money on medical treatment down the road, but is that really the only reason to do it? In fact, while it is unquestionably true that if fewer people smoked, more people ate a healthy diet and were physically active, the air was cleaner, etc., we would spend less money treating cancer, heart disease, and diabetes. However, it does not follow that every dollar spent to achieve those ends will save more than a dollar plus interest, since we're looking toward the future, in eventual health care spending. Interventions directed at a large population will be successful with only a percentage of individuals, and so the cost-benefit calculus is uncertain. The fact is there are few interventions that really save money in the end.

When it comes to preventive medical services, per se, there are really very few interventions that ultimately save money, and a lot of them, such as universal childhood immunization, are largely in place. There probably isn't a lot of room left to save money by investing in prevention -- certainly not enough to reverse or substantially slow the growth in health care spending.

However, that is not an argument for not doing more prevention. We don't spend money in order to save money, we spend money in order to get stuff that's worth it. And better health and longer life are worth spending money on. The issue is not just investing more in prevention -- it's allocating health care spending efficiently. As Woolf points out, insurers pay for many services that cost more than $100,000 per quality adjusted life year (QALY -- I've criticized the concept previously but we need some way of comparing benefits of various interventions); but there are services that cost much less that aren't universally utilized. For example, colonoscopic screening for cancer is estimated to cost less than $25,000 per QALY, but most people don't get it. Other preventive services cost even less. However, they still have a net positive cost.

Therefore, if we spend more on screening and prevention, in general we will end up spending more in total, not saving money, although we will prevent suffering and disability and extend lives. If we want to actually save money, we have to spend less on less cost effective services, and reallocate the spending to others that, while they still have a net positive cost, give us more for our money.

This means -- drum roll please -- we must have rationing. The so-called Free Market™ does not allocate health care resources in this way, and generates almost no public health resources at all, because they are public goods. The best way to achieve the rationing we need, from which we will all benefit (and I'm not one who believes that a terminal cancer patient actually benefits from $150,000 worth of chemotherapy that yields three months of sick and suffering life) is to have universal, comprehensive, single payer national health care. Yeah, socialism. There, I said it. When it comes to health care, capitalism is what ails us.


Unknown said...

My name is Konstantin Monastyrsky. I am a medical writer and an expert in forensic nutrition. I recently released an investigative report entitled “Death By Colonoscopy” on YouTube and my website. This report is based entirely on mainstream medical research, and is fully referenced (

I realize the title of my report sounds bizarre, but before you label me insane, consider the following well-established facts:

-- Colonoscopy screening increases mortality from all other causes, research shows. The Telemark Polyp Study I demonstrated a 57% increase in mortality among screened patients vis-à-vis unscreened controls. The decrease in the incidence of colorectal cancers was only… 2%, which, statistically speaking, is below the margin of error.

-- According to the CDC (Centers for Disease Control and Prevention), since screening colonoscopies started in earnest in 2000, the annual incidence of colorectal cancers has grown by 30,000 new cases, while the mortality rate remained practically unchanged.

-- Estimated 55,000 Americans die annually from colon cancer. According to the report entitled “Complications of Colonoscopy in an Integrated Health Care Delivery System” by the Annals of Internal Medicine, an estimated 70,000 (0.5% from 14 million+ screenings) are killed or injured by colonoscopy-related complications. This figure is higher than the total number of annual deaths from colon cancer by 22%.

-- The 18 years long Minnesota Colon Cancer Control Study included 46 plus thousand patients between the ages of 50 and 80. It demonstrated only a 0.6% reduction in the incidence of colorectal cancer. Statistically speaking, this difference is even less than the chance outcome of one thousand coin flips.

-- According to the Federal Drug Administration, X-ray exposure from a single virtual colonoscopy increases one’s lifetime risk of cancer by 20%. Virtual colonoscopies are now recommended every 5 years. By age 70 one’s risk of developing any other form of cancer grows to 100%. Killing you with another form of cancer before the colon gets affected is one hell-of-the-way to “prevent” colon cancer.

So before you decide to have a colonoscopy (or even if you have already had one), please watch my report and learn about the possible complications from my site. If you already have had a colonoscopy, and run into side effects, such as constipation, diarrhea, diverticulosis, and others, the site offers a very specific set of suggestions on addressing them.

P.S. If you have any questions related to my report, feel free to contact me by e-mail via my site.

Cervantes said...

Hmm. Well, I'd have to check those numbers -- they certainly do not accord with review articles I have read. There is no plausible reason I can see why colonoscopy would increase all-cause mortality -- I think there have been rare cases of elderly people suffering kidney damage from the high osmolarity laxatives that are often used in connection with the procedure. Now that this problem is understood, they are no longer used with high risk individuals. Also, "this difference is even less than the chance outcome of one thousand coin flips" is gobbledeygook.

Of course screening increases the incidence of cancer, that's the whole point - to find them. Any impact on mortality would take some years to show up. So those observations are entirely consistent with screening being effective.

"Killed or injured" includes minor injuries, and is not a category which can meaningfully be compared to numbers of deaths.