Tuesday, July 14, 2009

Rationing, Data-Driven Care - Comparative Effectiveness as a General Proposition - Worth A Damn?

I dare say that I have worked off my fundamental formula on you that the chief end of man is to frame general propositions and that no general proposition is worth a damn..General propositions do not frame concrete cases. The decision will depend on a judgment or intuition more subtle than any articulate major premise.

Oliver Wendell Holmes, Jr., 1841-1935

As a general proposition, cost effectiveness studies appeal to Medicare officials as cost-cutting tools. These studies are neutral, objective, and data-based. Yet as I talk to physicians in the trenches, they tell me clinical decision-making, and interactions between doctors and patients on the ground and behind closed doors, are more complex and variable than to-down bureaucrats and data mongers imagine.

Indeed, in my book Obama, Doctors, and Health Reform, I argue complexity is one of the fundamental obstacles slowing health reform, “American health care is a whirling Rubik's Cube, with millions of interrelated moving parts, institutions, and people, each with agendas, axes to grind, and oxen to gore.”

I conclude a chapter on complexity with these words,

“To understand health care and its complexities, you must examine its concavities and convexities, you must know what occurs at its edges, in the midst of the prickly hedges. Reality is never as simple as it seems, and you cannot always 'quantify' what matters through computer algorithms, which is why you, as a patient who uses the health system, should regard 'free health care,' as provided by the government, with deep skepticism. It may come with hooks – long waiting lines and restriction of choice of doctors.”

Take prostate cancer treatment options as a case in point. Here are the options and the costs.

Average Spending Over Two Years of Various Prostatic Cancer Treatments (Source: Alan Garber and Daniella Peffroth, Stanford; Dana P. Goodman, the RAND Corp.)

$2,436 – Watchful waiting, no intervention, with tests and exams – This makes sense in 75 year old with borderline PSAs and focal cancers. But what about younger patients with high PSAs and aggressive cancers? Do you tell them to take their chances because of lower costs and greater government savings? I don’t think so.

$12,224 – External beam radiation therapy, multiple doses of radiation over several weeks – This is relatively painless, noninvasive procedure with good outcomes. For this and other reasons, recommended by many doctors and accepted by many patients.

$22.921 – Complete surgical removal of prostate gland – Of great appeal to those patients and doctors who belong to the school “When in doubt, take it out.” To them it’s definite and offers the best hope of complete cure. Usually preceded by workup to make sure cancer has not spread.

$28,871 – Brachytherapy, implantation of radioactive seeds – Many recommend this approach as an effective shotgun approach to eradicate a multifocal cancer.

$51,069 – Advanced radiation beam therapy (I.M.R.T.) – This is a state-of-the-art high tech approach, and many hospitals are installing equipment to deliver the therapy. May be part of competitive hospitals’ marketing strategies to deliver the latest and the best.

One of the underlying appeals of a government-run system is its simplicity. The government pays for “everything,” but maybe not anything, depending on cost and effectiveness. Given the complexities and variables of prostate cancer and the desires, needs, and expectations of patients and desires of patients to please patients and deliver the proper therapy, the moral of this tale may be, “Seek simplicity but distrust it.”

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