Cost

This is a guest post from independent medical investigative journalist Jeanne Lenzer. She is a former Knight Science Journalism Fellow and a frequent contributor to BMJ, and has published works in  The Atlantic, The New York Times Magazine, Discover, The New Republic, and other outlets.

When doctors recommend tests, drugs or surgeries to prevent bad outcomes (think cholesterol-lowering agents to prevent strokes or cardiac stents to prevent heart attacks) they tap into our deepest sense of what constitutes commonsense: An ounce of prevention. Catch it early. A stitch in time.

It can’t be a bad thing to catch problems early, can it?

Unfortunately, one of the toughest things to explain is why detecting some illnesses at their earliest stages can cause more harm than good. Take this example: Since elevated cholesterol is associated with a higher risk of cardiovascular disease, doctors often prescribe drugs known as statins to people with elevated cholesterol levels in the hopes of reducing their risk of a heart attack or stroke.

Here comes the part that’s tough to explain – because it is so counterintuitive: Statins only help individuals who already have had a heart attack or stroke (with a few exceptions, and more on that later).

Of course, this makes no sense to most people. Isn’t the whole point of taking cholesterol-lowering agents to prevent a heart attack? Why should anyone wait until after a heart attack or stroke to begin taking a drug designed to prevent a heart attack or stroke?

The answer rests with disease creep and the simple statistical quirks that come with it. In the past, doctors treated diseases that caused symptoms. But now we have tests and imaging machines that can detect risk factors and illnesses in their earliest stages. Like cholesterol. Elevated cholesterol is not a disease. It doesn’t cause symptoms. It is a risk factor. People with high cholesterol levels are somewhat more likely to develop a heart attack or stroke, but they are at far less risk than individuals who already have cardiovascular disease. This is the definition of disease creep: when pre-conditions or risk factors are treated as if they are the same as the actual disease state.

Here’s a thought experiment (with purposefully exaggerated numbers) to help understand this puzzle: Imagine a group of people who have the rare but awful Disease A, which is so terrible that all of its victims will die. Now imagine the discovery of Wonder Drug X, which cures half of the patients with Disease A. Unfortunately, Wonder Drug X does have a pretty bad side effect profile – it’s a very powerful drug, after all – and 10 percent of people who take it will die from liver failure. Despite this worrisome side effect, Wonder Drug X is truly an advance for patients with Disease A: For every 200 patients with the disease who are treated, 100 will now survive and only 10 of the 100 survivors will die of the drug’s side effects. That means 90 more people out of 200 will survive thanks to Wonder Drug X.

But now imagine a different group of 200 people, who don’t actually have disease A, but instead have a genetic marker which “is associated with” Disease A. In this scenario only 1 in a million people in the general population will get disease A. If you have the genetic marker, the risk is much higher, such that 2 of these 200 people will develop the disease at some time in the future. The genetic test gets highly promoted – “find out your risk early, because we now have a treatment that works, and the sooner you’re treated, the better!” There is a tiny grain of truth to this – of the 2 people identified by the genetic test, 1 (50%) will now be saved by Wonder Drug A.   This might sound just as good as before; here’s a group of people with 10,000 times (!) the risk of the general population to develop a uniformly fatal disease. Surely it’s worth taking a drug that can cure that disease in half the cases, isn’t it?

But it really isn’t the same. Because saving that one life isn’t remotely worth the harm caused by Wonder Drug X in these 200 people. For while each individual is at a 10,000 fold risk of the disease, only 2 are destined to die from it. On the other hand, if they take Wonder Drug X, roughly 20 (10 percent of the 199 survivors) will die unnecessarily of liver failure.

Congratulations are in order for the cast and crew of Escape Fire: The Fight To Rescue American Healthcare.  The documentary was just picked up to premiere at the Sundance Film Festival in January 2012!

The film "examines the powerful forces trying to maintain the status quo, a medical industry designed for quick fixes rather than prevention, for profit-driven care rather than patient-driven care," and presents the vision of those medical professionals and other advocates working tirelessly for a more effective, health-centered system. You can see the trailer and more information here.

Once again, congratulations to the creators, Matthew Heineman and Susan Froemke, and to the rest of the cast and crew. We're looking forward to seeing the final product!

Three opinions. Right?

Well, apparently not--at least not on some issues. The University of Chicago's Institute on Global Markets has pulled together a panel of respected academic economists, and is asking them to agree or disagree with a series of policy-related statements. Watching the consensus (or lack thereof) is interesting on a variety of topics, but we found last week's statement particularly notable:

There are no consequential distortions created by the tax preference that favors obtaining health insurance through employers.

Obviously, we care because it's health-related, but the level of consensus is interesting as well. Contrary to the common perception of economists as constantly disagreeing with each other, 95% of economists surveyed either disagreed or strongly disagreed with the proposition. Taking their confidence in their answers into account, 97% disagreed (63% strongly).

The poll doesn't ask whether the employer-sponsored system, or even the tax preference, is a good thing--it only asks if it creates distortions. On that, the near-unanimity sends a strong messge: both labor markets and health care markets are affected by the subsidy. It keeps people pinned to jobs that they'd prefer to leave, and induces over-insurance and over-consumption of health care. Addressing that overconsumption--and the incentives that create it--is critical to bringing down our long-term health costs.

Thanks to Jodi Beggs of Economists Do It With Models for the tip on the IGM Forum.

Shannon Brownlee's newest piece at TIME Ideas calls the FDA's de-labeling of Avastin as a breast cancer treatment "one of the most important decisions ever made by a federal agency for the nation’s long-term fiscal outlook." We don't think that's an understatement.

The importance of the Avastin decision is twofold: it strengthens the institution, and it paves the way for making the hard-but-inevitable choices that will allow us to contain health care costs in the future.

As we've noted, the whole purpose of the FDA is to determine which drugs are safe and effective. Avastin used to treat breast cancer is neither for most patients, and until the manufacturer can show that there is a sub-population of patients that can benefit, women who take it are more likely to be harmed by the drug than helped.

Now, we need to go one step further, and acknowledge that when the FDA rejects a drug--not just when it has not approved it, but when it has actively rejected it--the fiscally and medically responsible choice is not to continue paying for the treatment. As Brownlee notes in the piece, it's not a small part of the cost problem:

"Avastin is just one example of the dozens, perhaps even hundreds of drugs, tests, surgeries and medical devices that offer marginal, if any benefit to patients, which we pay for nevertheless. To take just a single example, it’s estimated that about one-third of the imaging tests, the hundreds of millions of X rays, CT scans and MRIs that are performed each year, do little if anything to improve doctors’ ability to diagnose their patients’ conditions or change the course of treatment they recommend."

The FDA did the right thing last week when it removed its seal of approval from the use of Avastin in treating advanced breast cancer. The decision is a long time coming, given that its own expert panel recommended against approval in the first place, and that another panel recommended removing the breast cancer indication nearly a year and a half ago.

Still, this is an important and courageous move for the FDA: important because it implicitly acknowledges the FDA's duty to only approve drugs that are safe and effective; courageous because the agency will undoubtedly be raked over the coals for the decision. Members of the breast cancer advocacy community, like most other people, have a bias toward preferring action over inaction. Their frustration is understandable, as advanced breast cancer is a terrible diagnosis. For advocates of evidence-based medicine, however, it's time to stand behind the FDA. They're doing their job, and doing it well.

Several other blogs have made important points about the decision. The Incidental Economist provided an excellent list of all the things the FDA didn't do, including:

• "Pulling Avastin from the market;
• Banning use of Avastin for metastatic breast cancer;
• Punishing doctors who use it off-label;
• Banning reimbursement for off-label use; or
• Making a death panel decision based on inadequate scientific evidence."

Of course, the FDA can't do many of these things, but many advocates seem to forget that Avastin is still available, and it will surely still be used off-label. But at least oncologists and patients will be on notice that the risks of the drug are not worth taking, at least for most, perhaps even all patients. (There might be a small sub-population of women who benefit from the drug -- and maybe not. Genentech, the manufacturer, would have to do further study to identify those women.) We echo the Incidental Economist's exhortation to journalists: please don't make these mistakes again. Don't even imply them. No excuses.

GoozNews also pointed out that insurers are unlikely to drop coverage of Avastin for breast cancer, even without the FDA's word:

"most insurance companies and Medicare will continue to follow the National Comprehensive Cancer Network guidelines. NCCN’s guideline writing committee, a third of whom have financial ties to Roche/Genentech, has said it will not withdraw Avastin’s use in metastatic patients." (emphasis added)

We spend a lot of time combating myths about how doctors make medical decisions. Among the most prominent of those delusions is the belief that doctors don't order extra treatments based on how they're paid--rather, all of their recommendations and prescriptions are based purely on the patient's need.

We've pretty thoroughly established by now that we don't buy it.

This article from last week's edition of JAMA doesn't buy it, either. The study compared rates of stress-testing as a follow-up after heart surgery, based on whether patients went to a practice that typically billed for such testing or didn't bill. The practice's billing patterns indicate whether they do the tests that they order in-house (and thus profit by the test), or if they send patients elsewhere. The results were striking: patients in practices that both performed and interpreted the tests in-house were about twice as likely to get a stress echocardiogram or nuclear stress test (two kinds of high-tech stress test, measuring the flow of blood through the heart). For stress echocardiography, in particular, patients at practices who did their own tests were almost 13 times as likely to get the test as patients who would have had to go elsewhere. The differences aren't based on different patient populations, either - the study included adjustments for age, sex, and prior medical conditions.

It's long past time to start thinking about payment reform. 

Matt Yglesias of the Center for American Progress made a major departure from his usually well-reasoned analysis of politics and policy last week in his post, “America Needs More Doctors.” We felt it was important to set the record straight.

The mistake of thinking we’re going to run into a crisis-level physician shortage is an understandable one, given the dominance of that narrative among health policy observers. Most of the arguments are justified along the lines Yglesias uses: we spend a lot of money on medical care, and we pay higher prices for most of it than the rest of the world. We also have fewer doctors per capita than many other countries, especially in primary care. Add to that the limited number of residency slots that determines how many new physicians can enter the workforce each year and the rapid growth in our elderly population, and the problem seems obvious: Low supply equals high prices and therefore high health care costs.

Unfortunately, this analysis misses a couple of fundamental points. Most importantly, new doctors don’t go where they’re needed! When doctors leave residency, they tend to stay in areas that already have high levels of physician staffing. Part of this is due to the simple fact that many of the places where there are lots of doctors are attractive places to live (i.e. New York City). However, the wage adjustment that would normally happen when professionals over-concentrate in one location (i.e. wages drop in that area, and some people decide to move elsewhere to make more money) doesn’t happen much in medicine. Instead, as the Dartmouth Atlas has demonstrated, areas with lots of doctors see the volume of medical services delivered increase, allowing physicians to continue making high salaries even in places that are overendowed with doctors. One demonstration of the disconnect between need and physician distribution is in the graph to the right: there is practically no relationship between the number of very low birth weight infants and the number of neonatologists in an area. (Image from this paper.)

While it’s true that some parts of the US (particularly rural areas and inner cities) may be legitimately understaffed, it’s also important to note that not all low-supply areas have too few doctors. Rather, there appears to be some “threshold” level of physician capacity, below which people’s health suffers, but above which there are few additional health benefits.* That means in many parts of the country, we really don’t need all of the doctors that we have right now. We especially don’t need as many interventional cardiologists and other specialists as we have. (For reference, we have about two specialists per primary care doc, while other developed countries with as good or better health have about two primary care docs per specialist.) We should concentrate on getting underserved areas to have sufficient primary care capacity, but expanding capacity everywhere else is, at best, useless; at worst, it’s harmful because it will drive up spending without improving health.

The folks downstairs at the Committee for a Responsible Federal Budget clued us in last week to an ongoing debate they've been having with the Center on Budget and Policy Priorities. The central piece of the debate is CRFB board member Erskine Bowles's recommendations to the Supercommittee, which included about $600 billion in reduced Medicare and Medicaid spending. The posts are interesting throughout, and as the deadline approaches, we felt it was important to check in on the federal budget side of health policy.

Here's the debate, with a our commentary:

The initial post: Bowles Plan Offers Path to Compromise

The most important aspect of Bowles' plan, from our perspective, is the method proposed by the Fiscal Commission for fixing the Sustainable Growth Rate (the ironically unsustainable Medicare reimbursement cuts that Congress pushes back each year). In order to pay for a long-term "doc fix" (which would bring down spending on physician fees by cutting rates of reimbursement), the commission recommended that Medicare "develop an improved physician payment formula that encourages care coordination across multiple providers and settings, and pays doctors based on quality instead of quantity of services."

This recommendation is critical. Moving away from the current fee-for-service system is among the most important ways to change how doctors make decisions; at a bare minimum, the Supercommittee should recommend changing reimbursements to reflect the value of primary care instead of encouraging the overcapacity of specialists we have right now.

CRFB didn't specifically mention it, but another critical Medicare fix that the Fiscal Commission recommended is removing the hospital exemption from IPAB recommendations. Given that hospitals make up a huge amount of our total medical spending and are the setting for a huge amount of unnecessary treatment, it's crucial that IPAB have the authority to recommend changes that improve hospitals' incentives to treat patients efficiently.

Related to the initial post: Actually, Raising the Medicare Age Is Also A Good Idea

CRFB's discussion of raising the Medicare age from 65 to 67 is the primary inspiration for this post's second title: we just can't find any good reason to support it.  (If you're really interested in why, we recommend The Incidental Economist's podcast on the subject.)

The thing is, we agree with CRFB on the facts surrounding the issue. Raising the Medicare age would decrease federal health spending somewhat. (The CBO numbers they mention are higher than the ones cited by Carroll and Frakt in the podcast, but not unreasonably so.) On the other hand, they also acknowledge that the shift would increase costs in the private market beyond the savings to the government (because Medicare pays lower reimbursement rates than private insurance). We at New Health Dialogue are concerned with the high total level of spending on health care, rather than simply the level of federal spending on health care. Unnecessarily increasing total medical spending therefore seems like a high cost to pay for a slight reduction in the federal budget which would probably be shortlived, since many of those 65-67 year olds would need help getting insurance, probably through the exchanges specificed in the ACA.

CBPP's initial response: Bowles “Compromise” Proposal to the Right of Boehner Offer to Obama in July

We have to point out a framing problem in CBPP's analysis: not all Medicare and Medicaid cuts are created equal. Some cuts (like those generated by raising the Medicare age) are simply shifting costs from the federal budget to beneficiaries. Those can be fairly labeled as "cuts," and they do increase the burden of health care spending on the elderly. Some of the $600 billion in lower Medicare/Medicaid spending, though, is intended to come from eliminating overtreatment and waste in the medical system. We're well aware that "eliminating waste, fraud, and abuse" is usually what politicians say they'll do to pay for things that they have no intention of actually paying for. However, the Dartmouth Atlas and other analyses have demonstrated that health care really does have a huge amount of wasteful care. Deciding to give patients only the medical care they need, rather than whatever local practice patterns dictate, deserves to be called what it is: responsible management of taxpayer dollars (and of the health system more generally). Demagoguing against such cuts because they reduce health entitlement spending ignores the possibility of making the health system work better, and stands in the way of real progress.

Here’s a list of the recent fibs, misdirections, misstatements and outright lies uttered by a wide variety of opinionmongers in reaction to the new guidelines on prostate cancer screening with the PSA test issued by the U.S. Preventive Services Task Force.

CLAIM 1:

“There weren’t any urologists on the task force!” This was uttered by none other than Newt Gingrich, former Speaker of the House and now-presidential candidate, during the Republican debate at Dartmouth College this week. The charge was also leveled by Dr. Patrick Walsh, University Distinguished Professor of Urology at Johns Hopkins Medical Institutions. (Walsh also pioneered “nerve sparing surgery,” a technique for removing the prostate that helps preserve a man’s ability to get an erection.)

They’re right: there were no urologists on the task force. Instead, there were 15 experts, all of whom have advanced degrees in addition to their medical training, and the statistical knowledge to parse medical evidence. You don’t need to be a urologist to dissect a scientific study, and there are plenty of urologists out there who wouldn’t know the first thing about doing so.

Perhaps Paul Goldberg, publisher of The Cancer Letter, said it best when describing the urologist Gingrich cited: “I wouldn’t call him an expert in prevention; I would call him a urologist.”

In light of the media discussion surrounding PSA testing at the moment, Health Dialog (a producer of patient decision aids for medical decisions) is making their PSA test decision aid available free of charge on their website. The decision aid includes video, booklet, and web-based formats, and presents the evidence about the risks and benefits of PSA testing impartially. If you are a man considering having a PSA test, the decision aid may help you come to an informed decision.

The medical blogs are on fire this week with comments about the US Preventive Services Task Force (USPSTF)'s newest recommendation on the prostate specific antigen (PSA) test. On the basis of the latest scientific data, the task force is now recommending against PSA screening. An earlier recommendation said that routine screening was unnecessary in men over 75, or those with life expectancy shorter than 10 years; the update will recommend against routine PSA testing for any man of any age.*

Not surprisingly, this has set off an angry howl from many pro-PSA patient advocacy groups, some physicians, and battalions of outraged men, many of whom gave personal testimonials to the effect that the PSA test saved their lives. In the words of one Bruce Rogers, from Champain, Ill., "Were it not for the PSA tests, today I would be dead and buried."

Of course, all the men who have died from the treatment for prostate cancer or are too sick or debilitated to get to their keyboards aren't able to tell their side of the story, and whether or not the test actually saves lives is at best debatable. (You can read about the evidence for and against the test in a story that will appear in this Sunday's New York Times Magazine.)

The other common reaction to the new task force recommendation was expressed by a fellow calling himself "whoami2day," who wrote in response to a CNN story:

"Here we go again. OUR government in the pockets of the insurance companies and oil companies. How much longer are we going to put up with this crap.  . . . "

In other words, the task force's recommendation is all about saving the government money by denying men a test that could save their lives. Whoami2day is right that the debate over PSA testing is partly about money, but he may be targeting the wrong villain.