“There are Five Things that Can Happen as a Result of Screening Tests, and Four of Them are Bad.”
Another great article on this subject by Natasha Singer in the New York Times, with this to say:
Saving one man's life from [prostate cancer] would require screening about 1,400 men. But among those 1,400, 48 others would undergo treatments like surgery or radiation procedures that would not improve their health because the cancer was not life-threatening to begin with or because it was too far along. And those treatments could lead to complications including impotence, urinary incontinence and bowel problems.
Interesting. The solution is to have people make their own decisions about these tests, spending their own money from their own Health Savings Account.
Another misleading article from the NYT. It says “A recent European study on prostate cancer screening indicated that saving one man’s life from the disease would require screening about 1,400 men. But among those 1,400, 48 other would undergo treatments like surgery or radiation procedures that would not improve their health because the cancer was not life-threatening to begin with or because it was too far along.”
This just isn’t true. If one tracks through the links to the actual study in the NEJM (Mar 26, 2009), it says that to prevent one additional death, 48 men would have to be treated and that the actual treatment of prostate cancer was “performed according to local policies and guidelines” in the multicountry study. For indolent cancers this could simply be watchful waiting.
The study also says that there was “little indication of differences [in treatment] between the two study groups after adjustment for disease stage, tumor grade, and age…”
So, if I’m getting the drift of the paper on the European study, the screening finds cancers, and the cancers get evaluated for appropriate treatment. Individual risk is reduced, at the cost of the higher expenditure for the screening, higher follow-up costs, and the possibility that false positives lead to needless biopsies.
However, once the tumor is found, the treatment and control groups received the same treatment. One therefore wonders what the basis is for the NYT claim that the additional 48 people referred for treatment as the result of screening would end up being given treatments that may not improve their health and “that could lead to complications including impotence, urinary incontinence and bowel problems.”
I think a little too much attention is being paid to the effectiveness of screening techniques and whether we should promote them. The real question is who should be making the decision about what to do and what goes into that decision.
Patient advocates want everyone to understand their relative risks, the effectiveness of the various screening and treatment options, and for people to have access to them. We also want the decision to have them or not to be made between the patient and his or her doctor, not by the government or some other impersonal third-party. Yet the fiscal conservative in us knows that screening the whole population for all these diseases will get way too expensive!
Here’s the problem as you’ve commented before. In the current health care system, “almost everyone faces perverse incentives. This includes almost every patient, every doctor, every nurse, every hospital administrator, every employee, every employer, every insurance company, every government agency….. (did I overlook anyone?). By perverse incentives I mean that when people act in their own interests, they usually impose external (social) costs on others. This means that social cost is likely to exceed social benefit for every actor at every margin.”
“Take total spending on health care. It is the outcome of about 300 million patients and about 800,000 doctors all interacting in complex ways. But it is also the simple, straightforward sum of what I and my doctors spend on my care plus what you and your doctors spend on your care….. etc., etc.,…..summing over 300 million people. No matter what else happens, if I and my doctors don’t change what we are doing for me and you and your doctors don’t change what is being done for you….. and so forth….. aggregate spending will not change.”
In other words, right now the doctor has a perverse incentive to order every test, because they are paid by task. The patient has the perverse incentive to ask for every test, because they are typically shielded from the true cost. This is very wasteful. But, as you say, “I’m wasting your money (you being the other members of my insurance pool), not mine. If I am a representative patient, every time I spend a dollar only 13 cents will come out of my own pocket.” The bureaucrat (insurance or gvt) has the perverse incentive to deny every request because they are the ones really paying for them. The hospital administrator has the perverse incentive to restrict access to tests, usually by delay, to those without adequate coverage (this includes those on Medicare and Medicaid). The nurses and other folks at the hospital, such as lab techs, etc., have the incentive to drag their feet and put pressure of docs not to order tests because they are running at full capacity.
Under Congress’s reform plans, this gets worse This is basically what CBO just said this week.
Your point about increased access is also informative here. “Millions of uninsured people will be mandated to obtain insurance and many of the people who are currently insured will get more generous insurance. As a result, these people will use their newfound coverage to try to obtain more care. But where will they get it?” Rationing will be the answer to increased demand where supply won’t change much.
A better, conservative approach would be a system of universal refundable tax credits to increase access to private insurance and a greater movement towards consumer-directed health care. That way the insurance sold in a national marketplace freed of costly state regs can cover the catastrophic care associated with treatment. Insurance will now be incentivized to encourage early detection so that treatment costs are lower. The educated patient can make routine screening decisions, now that they are bearing the true cost of the procedure from a special dedicated account that they own and control, in consultation with their doctor, who now sees his patient as the true client. The doctor is also able to make new payment structures, some of which may save the patient money, such as a combination of payment based on time, task, retainer, etc. There will still be rationing, but it will be done by the patient, determining what best for their health and their pocketbook.
Sounds like Patient Power is the answer to me.
Linda, we can always count on you to set us straight on these things. So glad you are blogging here.
Sean, totally agree. When procedures do not pay for themselves, as these do not, they must trade off against other uses of money. There is no one better to make those tradeoffs than the patients themselves.