In a sane society, “Comparative Effectiveness Research” would not even be controversial, let alone be held up as the moral equivalent of murder. Hell yes, of course we need to evaluate clinical treatments for their effectiveness, and discard those which are not effective. That ought to be a no-brainer.
I vowed to myself I wasn’t going to write any more essays about health care reform, but an article in today’s New York Times has set me off yet again.
The article quotes 79-year-old James T Aronis:
"'I had prostate cancer,' he said. 'My doctor removed it immediately, one day after getting the results of a biopsy. That probably would not happen under the new health plan.'"
If only.
A study published in the New England Journal of Medicine followed 695 men diagnosed with prostate cancer and randomly assigned them to either radical prostatectomy or watchful waiting. The study found radical prostatectomy cuts in half (but does not eliminate) your chances of dying of metastatic cancer, but there was no significant reduction in overall mortality. What difference does it make if you die of prostate cancer, or you die of something else at the same time? We all have to die of something.
So here’s a fellow afraid Medicare won’t fund an intervention which does not save lives, and which carries with it a significant risk of urinary incontinence to boot. If the opponents of healthcare reform can’t find a better example than that to stoke people’s fears, they ought to hang it up.
We are an insanely overmedicated nation, and our elderly population is especially vulnerable. And I freely admit that extending the same level of overmedicalization to everybody would break the bank. But that’s not what I have in mind at all.
What I have in mind is a system like the National Health Service in the UK, in which interventions are evaluated by the National Institute for Health and Clinical Excellence. Those which are judged not to be cost-effective are not indemnified.
Yes, I’m advocating rationing health care. But we already do. We will ration health care, and every product and service, under any conceivable system of incentives, because our desires are infinite and our ability to satisfy them is not. The difference is, in the UK, health care is rationed on the basis of evidence, in a transparent manner, whereas in the USA health care resources go primarily to whoever has the money to pay for lobbyists to leverage other people’s tax dollars. And in the UK, everybody is covered, while per capita spending on health care is less than half of what it is in this country.
I am sure their system doesn’t work perfectly. It’s true that every once in a while I read some sob story about someone in the UK who is denied some intervention that may or may not tack on a few extra weeks at the end of life. At least there they won’t charge you $8,800.00 for giving birth to a healthy baby. That strikes me as infinitely more important. And life expectancy is higher in the UK than it is in the US.
Part of being a functional adult – Hell, part of being functional five-year-old – is recognizing that you can’t get everything you want. The NYT article I cited above concludes with these portentious words:
”The 1965 law that created Medicare prohibited ‘any federal interference’ in ‘the practice of medicine or the manner in which medical services are provided,’ or in the operation of any institution providing health care.
“Sara Rosenbaum, a professor of health law and policy at George Washington University, called this 'a majestic message from Congress about how it expected the Medicare program to be run.'”
What Sara Rosenbaum calls a “majestic message,” I call a “blank check.” And it’s time those of us who are footing the bill stood up and said we can’t afford to write any more blank checks.
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Dr. Evan Levine
old new lefty
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but if it makes you feel better, go right ahead.
With regard to prostate cancer treatments:
While prostate cancer is generally slow-growing in men ages 75 and older, and in general men of those ages diagnosed with prostate cancer are much more likely to die of something else before the cancer does them in, there are still legitimate reasons to treat the cancer in some cases. For example, if a mass is causing urinary or intestinal blockage, or causing great pain.
I discussed this in some detail on my own blog (the post is titled, "What Good Is An Erection When You're Dead") and also on the blog of a certain doctor (whom many of us love to dislike) right after that study came out. Point of fact, there were actually two similar studies, one showing a 20% reduction in prostate cancer mortality.
That said, we absolutely need to ration healthcare, but we need to do it in a compassionate, reasonable manner. There are many, many areas of wasteful spending in healthcare today that could be reduced or even eliminated with very little effect on our citizens.
However, I am not comfortable with the government setting absolute limitations on allowed treatments. We need to set up a system in which cases meeting specific criteria can be reviewed, and a determination can be made by medical professionals as to whether a typically denied treatment would be appropriate. This is what the insurance companies are supposed to be doing, but it is currently done with an eye for profits rather than the health of the patient.
We also need to start changing the current attitude in healthcare. Rather than prescibing new medications for new symptoms, we need to look at the current prescription regimen to determine whether the new symptoms stem from a particular medication or medication "cocktail". We need to stop writing so many prescriptions, and we need to stop expecting our doctors to fix our every complaint with a "magic pill". Doctors need to stop prescribing expensive physical therapy as a prerequisite to certain types of surgery (as currently required by many insurance companies), particularly where the P.T. is actually harmful to the patient. In short, we need some "uncommon" sense. Reform needs to begin immediately, at the med school level and in required Continuing Medical Education (CME) courses.
I recently completed a series of blog posts on healthcare reform, detailing our current problems, what we need and how to pay for it. If you're interested, stop by and feel free to critique.