The Price of Marginal Thinking in Healthcare Policy

I find it fascinating how our brains have this propensity to latch on to what is at the margins at the expense of seeing the bulk of what sits in the center. This peripheral only vision is in part responsible for our obscene healthcare expenditures and underwhelming results.

I have blogged ad nauseam about the drivers of early mortality in the US. In one post I reproduced a pie chart from the Rand Corporation, wherein they show explicitly that a mere 10% of all premature deaths in the US can be attributed to being unable to access medical care. The other 90% is split nearly evenly between behavioral, social-environmental and genetic factors, of which 60%, the non-genetic drivers, can be modified. Yet instead of investing the bulk of our resources in this big bucket of behavioral-environmental-social modification, we put 97% of all healthcare dollars towards medical interventions. This investment can at best produce marginal improvements in premature deaths, since the biggest causes of the effect in question are being all but ignored.

A couple of other striking examples of this marginal magical thinking have surfaced in a few recent stories covered with gusto in the press. One of the bigger ones is the obesity epidemic (oh, yes, you bet it was intended), and its causes. This New York Times piece with its magnetic headline “Central Heating May Be Making Us Fat” entertains the possibility that because of the more liberal use of heat in our homes we are no longer engaging our brown fat, which is a furnace for burning calories. And this is all well and good and fascinating, in a rounding out sort of a way.

And it is just as interesting to hear that lack of sleep may be contributing to our expanding waistlines. But it is also baffling that we are still expending these enormous amounts of energy (OK, this one was not intended) on finding the silver bullet, when the target is not a supernatural being, but a super-sized expectation. Is it really that mysterious that we are fatter now than we were 20 years ago, when our current portion sizes are 70% bigger and we spend our days worshiping at the temple of the screen, in all its manifestations? While I am all for learning as much as we can, what we need right now is immediate action to abrogate this escalating epidemic, and I think we can all agree that the way to do it is not through lowering house temperatures. Plenty of behavioral research is available to inform our strategies to get people to eat less and move more. Let’s start translating it into practice rather than latch on to one marginal magical idea after another.

And finally, I have to touch upon lung cancer, of course. The current fodder for this was provided by the Washington Post with this story about the growing advocacy among lung cancer patients for early detection. You may recall that recently I did several posts on the heels of the large NCI-sponsored study National Lung Screening Trial (NLST) whose purpose was to understand whether early detection of lung cancer in heavy smokers may improve lung cancer survival. I do not wish to go into all of the specifics of this study and my interpretation of the results — you can find my thoughts on this study in particular and on screening in general here. What I do want to reiterate is that 85% of all lung cancer is caused by a single exposure: smoking. And guess what? The same behavioral strategies that can help people stop overeating can be deployed towards smoking cessation. Yet, instead of spending 85% of all expenditures on smoking cessation efforts, we prefer to allocate it to early detection. My point is that we need both, but the balance has to be informed by pragmatism, not the marginal magical thinking.

And so it goes that the Pareto principle is bleeding into our healthcare policy decisions — this is the steep price of the marginal magical thinking. What will it take to get the blinders off and face up to the idea that some intervention points are just more impactful than others? Marginal panaceas will improve our lives, but only at the margins. And without being addressed, the big elephants in the room are likely to stampede us.

Marya Zilberberg, MD, MPH, is a physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is the Founder and President of EviMed Research Group, LLC, a consultancy specializing in epidemiology, health services and outcomes research. She is also a professor of Epidemiology at the University of Massachusetts, Amherst. Dr. Zilberberg is a member of multiple journal editorial boards and is frequently invited to speak about evidence-based medicine, research methods and healthcare-associated complications. She blogs at Healthcare, etc.

5 replies »

  1. Also, a football players average career length generally isn’t that long–2.66 years according to SportsIllustrated. Def need coverage.

  2. Such a good reality check – thanks. Two days ago I had occasion to use ER services for a family member. What struck me was not the slow service, but rather that not a single caregiver, clerk, etc was “right-sized” or healthy looking. The doc wasn’t overweight, but looked like a smoker and possibly a drinker. The rest of the staff members ranged from overweight to grossly obese. These are people who should be setting examples. Or at the very least, should be scared enough by what they see in the ER to reassess their own lifestyle choices. The security guard, whose abdomen completely covered his thighs down to his knees and whose job consisted of sitting on a stool and pressing a button to override the security alarm (yes you read that right) without checking to see what triggered it, looked ready to succumb to an imminent cardiac event (or drop dead of exhaustion from carrying all that weight around). I could go on and on but you get the point. Health care costs won’t be reined in until people take responsibility for their own health choices. And sadly, I don’t see that happening.

  3. This post deserves better comments than the ones above, which seem spammy to me (apologies to their authors if they are not).
    I, too, saw that Washington Post story and thought, “hmmm, this calls for some thinking.” I’ve got new survey data which includes people living with lung conditions (N=360), of whom 66% go online (so the net for internet users in the group is N=213, just enough for good comparisons with the general pop). Internet users with lung conditions are more likely than other internet users to use the internet to get info about certain treatments, drug safety or recalls, environmental health hazards, memory loss, and how to manage chronic pain.
    I just released a cut at the data (see: http://pewrsr.ch/e7vccs) with more to come this spring.

  4. Great post, a lot of people are ignoring the benefits of health insurance and that is not good. I was just reading an article about how professional athletes have to pay a lot of money for their policies, but it’s so important for them to have that coverage since any sort of injury could cost up to millions of dollars to fix.

  5. What is thought of the analysis of Gary Taubes in “Good Calories, Bad Calories”? Most of my work has been in acute care nutrition, but his constructs (what happens in fat/lean compartments; transfer of substrates between compartments) are the most useful in acute care nutrition as opposed to “total calories” and weight. I found controlling blood sugars helpful in improving outcomes but also found reducing CHO load as important or more important than aggressive insulin therapy. So his analysis of the negative effects of insulin really struck a chord with me.