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So Much For Comparative Effectiveness

The Obama administration’s commitment to cost control in health care can now be summed up in four words: Not on our watch.

Health and Human Services Secretary Kathleen Sebelius told American women this week that they have nothing to learn from the science that led to the U.S. Preventive Services Task Force guidelines on mammography.Insurance companies won’t change their payment policies, and the independent doctors and scientists who made up the USPSTF task force “do not set federal policy” or determine what services are covered by the federal government.”

What a golden opportunity has been missed to educate Americans about the implications of their health care choices. Otis W. Brawley, the chief medical officer of the American Cancer Society, in an op-ed in today’s Washington Post condemning the USPSTF guidelines, confirms that mass screening would only save at a maximum 600 out of the 4,000 women under 50 who die of breast cancer annually. What he failed to point out is that 1.14 million American women would have to be screened annually for ten years to achieve that goal. To cover the entire cohort (all women between 40 and 49) to replicate that benefit every year would require screening 11.4 million women annually. The cost, at $200 per mammogram (my initial estimate was accurate, according to this New York Times business section article), would come to $2.24 billion annually for the health care system.

I repeat my argument from Tuesday. Let’s start on day one and ask this question: The health care system (you can’t say the government in our mixed public and private payer system) has just come up with an extra $2.24 billion to spend on reducing breast cancer mortality in the U.S. population. Not only that, we get to spend it year after year. Should we spend it on mammography for women under 50? Or should we target that money for free mammograms for women of all ages who smoke, who are obese and who have a family history of breast cancer? Should we target that money to free mammograms for women of color, who have a much higher risk of breast cancer (perhaps because they are more likely to smoke or be obese)?

And as far as the coverage is concerned, I have yet to see a single story that quantified the harms of mass screening. How many false positives and unnecessary biopsies are there for every breast cancer caught early? How many actual, treated positives turn out to be very early stage ductal carcinoma in situ, minor breast duct growths that may dissolve on their own? A recent AHRQ analysis suggested that was about 20 percent of all growths identified during mammograms. According to Greg Pawelski’s most recent comment on GoozNews:

Research by the Nordic Cochrane Centre in Denmark raised questions about the effectiveness of mammography. In a study of 2000 women, they found that one woman would have her life prolonged but 10 would undergo unnecessary treatment and 200 women would experience unnecessary anxiety because of false positive results.

Health care is complex. Most treatments that “work” only work in a fraction of the people who get that treatment. Each has risks, which also affect a subset of those treated. Evaluating value is a trade-off between risks and benefits. Because breast cancer is such a high profile issue, the new mammography guidelines offered the Obama administration a chance to educate the public about the trade-offs involved in making those choices, and how the nation might wring more value out of the money it spends on health care.

Alas, the administration punted. In the midst of a political battle over health care reform, where nihilist Republicans are braying about profligate spending on the one hand and letting nothing stand between you and your doctor on the other, the politicians in charge of health care policymaking saw that offer as one they had to refuse.

Correction: An earlier version of this post mistakenly said there were 4,000 deaths from breast cancer per year among women under 40. I meant women under 50. And Greg Pawelski is not a physian or a Ph.D.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics
correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and The Fiscal Times. You can read more pieces by Merrill at  GoozNews, where this post first appeared.

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Sara BrickmanSteve Beller, PhDsickoc3Ron Recent comment authors
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Sara Brickman
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Just like Ms. Gur-Arie states about graduating more doctors–as a new-nurse and sick and tired of hearing about the nursing shortage in the U.S…why aren’t there monies invested in more nursing programs? And if the so-called Magnet hospitals only want an RN with a BSN degree and moan and complain that they have a shortage–why don’t the hospitals work out an incentive program with the associate’s nurses to obtain a BSN? I am so confused and angry when I hear that the U.S. is going on a crazed nursing recruitment from the Phillipines and other countries to “fill the nursing… Read more »

LisaLindell
Guest

When will Dartmouth report on the cost of medical errors/poor quality? Of those they studied, how many were in their last 2 years of life because of their medical treatment?

Lisa Lindell
Guest

And why do we limit the ratio of teachers to nurses in nursing school, but no limit on nurse-to-patients? Bev MD, I read the beginning of your long post, I’m not asking why it’s taking so long, I already know why. Lack of leadership. Dr. Berwick has said pretty much the same thing, why are we pouring so much money into hc and not looking at the value we’re getting for our dollar? You’re just not angry enough, Bev MD. Margalit is correct if information were made public, that would be a good start. Patients don’t have a choice and… Read more »

Margalit Gur-Arie
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Margalit Gur-Arie

And as long as we are talking about preventable errors, why do residents have to work insane hours?
http://blogs.wsj.com/health/2009/11/23/ama-dont-guarantee-naps-for-residents-on-overnight-shifts/
Before anybody says that there aren’t enough of them, why are we not graduating more doctors? Medical schools are turning away thousands of qualified candidates each year.

Margalit Gur-Arie
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Margalit Gur-Arie

Bev, patients don’t actually have to pay in order to influence quality. Besides, hospital care is frequently in the catastrophic bracket for most people.
However, if the data was collected and made public (feds can do that), it is likely people would chose hospitals with better records, and if you want to encourage that behavior, reduce the copay for the “good” hospitals. I think Barry was suggesting tiered copays as a way to reduce costs.

bev M.D.
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bev M.D.

Lisa; There are many others smarter than me who can explain why the system has not changed faster; Don Berwick being one (see his book “Escape Fire.”) The causes, like errors in all organized systems, are multifactorial. However, here’s how I see it as a retired hospital-based physician. I confine my remarks to inpatient care as that is my area of experience, but what goes on in physicians’ offices (which I have experienced as a patient) is another novel in its own right. 1. The process of taking care of a sick inpatient is recognized as more complex than almost… Read more »

LisaLindell
Guest

Bev, how would you work with a system to change it? How would you personally go about doing that when that system tells you to go away? I spurn a government working against me. MD as Hell you are correct, especially teaching hospitals and we’ve been offering that advice for years, stay away from teaching hospitals. Bev, is a decade your definition of “yesterday.” How long are you willing to wait? Lucian Leape asks the same question, you willing to wait 100 years? You’re wrong, there is leadership for change (ie: Don Berwick) but there’s just not enough like him.… Read more »

bev M.D.
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bev M.D.

Lisa; I am not familiar with you or your posts, but you can choose to be angry and want everything to change yesterday, or you can choose to work with the system and help change it, as Sorrel King has. There are so many problems with health care delivery today, one could spend weeks sitting in a room writing them all down. I do not accept your view that everyone in health care has your worst interests in mind; but a chaotically inefficient delivery system makes errors inevitable. A punitive legal system encourages if not demands silence (I have been… Read more »

MD as HELL
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MD as HELL

Lisa,
I get the patient out of the healthcare system as fast as possible. That is the only safe play. Hospitals are very dangerous places and getting worse every year.

LisaLindell
Guest

Bev MD thanks for trying to be helpful but you are not telling me anything I don’t already know. I’ve been a pt safety advocate for the past 6 years, I know who and what everybody and everything is in this movement. I am correct about medical errors. Progress has been painfully slow, way too slow, and medical errors are a significant cost driver. As I have said in other posts, I have a real problem being mandated to finance this industry. You should, as well. We should all be outraged by the amount of money pouring into this industry… Read more »

bev M.D.
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bev M.D.

LisaLindell: You are no longer correct about medical errors. Although it is (too) slow, attitudes concerning these errors are changing. There is movement toward and even some federal and state mandates regarding full disclosure and quality improvement. I just read “Josie’s Story”, by Sorrel King, concerning her daughter’s death by medical error, and the foundation for patient safety which she set up with the settlement money from Johns Hopkins. (www.josieking.org, I believe, is the website). I recommend you read this book. I am retired now but am fairly well read on the patient safety movement and can vouch for the… Read more »

Steve Beller, PhD
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What would it take for clinicians and patients to know with a reasonable degree of certainty whether a particular test, procedure, medication or other action–for a particular patient with a particular condition (or conditions/co-morbidity)–is worth the money (i.e., is cost-effective)? Yes, we already have such knowledge in some situations, but ignorance often (usually?) prevails. We ought to engage in earnest in an evolutionary, interdisciplinary, worldwide collaborative process of knowledge building, guideline dissemination, and ongoing assessment & revisions that is guided by sound science. And we ought to continue as long a humanity exists. The current day controversy, imo, simply points… Read more »

jd
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jd

MD as HELL, I was asking a question because I haven’t dug into the details myself, but have heard that reform was enacted and that it reduced med mal lawsuits, but that practice patterns hadn’t changed. Peter and LisaLindell raise I think the most relevant point related to costs: if the lawyers have a low-enough cap on their fees, they aren’t going to take many/any lawsuits where they are paid based on the award. Here is a link on the effect of the legislation that indicates the malpractice reform in Texas went way beyond caps on damages and had a… Read more »

Anonymous
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Anonymous

C3 and bev, all good points and examples. I’m not a clinician (I’m one of those evil insurance types- hopefully I’m an Enlightened Insurer) so defer to your experience. Your examples raise an interesting thought about the effect that lag of information and practice changes have on healthcare. At a single point in time, a medical service’s value/benefit can be 1. unknown, but believed to be beneficial, 2. confirmed to have known value/benefit and in current use, 3. of dubious value or harmful, and no longer used, or unfortunately 4. of dubious value or harmful and still used. There was… Read more »

LisaLindell
Guest

The caps on damages in Texas are effective at keeping victims out of court. Good luck finding a lawyer in Texas to take a med mal case. Your suggesstion of “health courts” presided over by judges with a medical background smacks of the cronyism that already exists in every regulatory agency involved in the health care industry. From medical boards to the Joint Omission, nobody is protecting the patient from harm. N O B O D Y. Defensive medicine? Unreasonable patients? And still nobody is discussing the cost of medical errors. Let’s all just ignore that problem and pretend it… Read more »