- The Washington Times - Wednesday, February 10, 2010


Only in medicine do we pretend that costs don’t count. The nation has concurred by adopting a legal and moral standard that patients should not be deprived of anything that is medically beneficial no matter how minimal the benefit and how great the cost. Under existing law, Medicare cannot even consider cost in determining whether to approve a test or procedure for payment.

That’s what is at the core of the health care reform dilemma and what guarantees that all the plans under consideration from Republicans and Democrats will have only a marginal impact on the rising cost of health care.

Consider how abnormal this “spare no expense” thinking really is. Every family faces innumerable decisions that involve trade-offs in the use of money. Should we buy new shoes for the kids or, instead, use the money toward a weekend at Disneyland? One of those choices might be viewed as an essential and the other as nonessential. So perhaps the better question to ask would be whether to buy new shoes for the kids or first spend the money on pants, dresses and jackets. Only when the supply of money is unlimited can we gratify all spending impulses promptly and independently.

Of course, the reality in medicine is quite different. Costs do matter, and Medicare and Medicaid as well as private insurers use some form of “utilization review” to decide whether to pay for specific tests, procedures and operations. What they do not do is acknowledge that cost is the driving force in the decisions. Instead, their verdicts speak to “medical necessity” and “evidence-based guidelines” - suggesting that it would be wrong to pay for care that isn’t necessary or that hasn’t been documented adequately in the scientific literature to be of benefit. It is an open secret, however, that the more costly the claim, the more intense the scrutiny.

But what if the flagship payer - Medicare - were to explicitly include cost as a reason for approving or disapproving a medical service? That was a major change that was quietly embedded in the Senate health care reform bill, which established an “independent Medicare commission” to determine what services would be covered by Medicare in the future. Two questions immediately present themselves: Is the service worth the money? And are you worth what Medicare would be spending?

Both questions are vexing. The first one blends highly precise medical science that defines the effectiveness of a procedure, a drug or an operation with economic considerations that are far less precise and nonobjective because they are value-laden.

The results are endlessly arguable. Reasonable people differ in their perception of worth.

And amidst this spectrum of opinion, should a program like Medicare that is designed to cover the entire population of elderly and, to a lesser extent, the disabled, set spending limits that will pit the individual who disagrees against the government?

The second question touches on the issue of “medical futility.” How helpful does a treatment have to be to be authorized? Are terminal patients to be kept alive endlessly? Is a high likelihood of significant benefit to be the standard? Or should it be any benefit at all no matter how minimal and how unlikely to affect the ultimate prognosis? And what about non-terminal patients who are not fully normal to begin with - such as those with Down syndrome? Are they to be treated differently?

The proposed Medicare commission would have to grapple with and resolve such dilemmas. The decisions made would have life-and-death implications. Moral and financial considerations both would play a part in an ill-defined combination that could be manipulated easily. Should a mother of a child with Down syndrome (like Sarah Palin) be worried by such a prospect? Would it be irrational for her to see an all-powerful review board as a death panel? I think not. Might others who see themselves as medically “ordinary” be less concerned? Of course.

Here we see a political divide that only enlarges and hardens when powerful outside constituencies weigh in. Consider something far less complex - the commotion over new breast cancer screening guidelines issued by the U.S. Public Services Task Force in November. The task force, which is federally funded but operates independently, advised that women who do not have an increased risk for breast cancer should wait until age 50 (rather than age 40, as previously had been the standard) before beginning to get regular screening mammograms for early cancer detection.

A storm of protest erupted, led by the American Cancer Society, radiology and oncology organizations, lay groups and, of course, the manufacturers of mammography equipment. They were joined in their vehement opposition by breast cancer survivors.

Republicans called this the opening salvo in the Democratic administration’s plan to impose health care rationing as an integral part of health care reform. Democratic politicians back-pedaled furiously, reassuring American women that their access to mammography would not be interfered with under health reform.

What are the facts? For every 1,300 mammograms taken on women older than 50, a new breast cancer is discovered. But for women between 40 and 50, it takes 50 percent more - 1,900 mammograms - to detect one new case of breast cancer. Because breast cancer is less frequent in the younger group and because there are many false positives and biopsies that turn out negative, the task force did not recommend them.

The media were quick to point out that even though there are fewer positive mammograms in younger women, a life saved is still a life saved, and that remains true even though it costs at least 50 percent more to detect them. The American Cancer Society and some medical specialists also made much of the presence of generalist physicians on the task force, implying that they knew less about the disease and perhaps weren’t qualified to give advice.

That criticism stung because generalist physicians are a small handful represented among the 112 medical specialty organizations designated by the American Medical Association that have any serious role in overall health spending. When I began my own practice of internal medicine in the 1960s, most patients were poorly insured, and I had to advise them on the most effective use of their limited funds. It wasn’t easy, and my advice was highly valued. Since then, insurance has improved, costs have soared, and by the 1990s, there was renewed interest in using primary physicians to prioritize the need for care. Only this time, it was on behalf of the insurance carriers and not the patients. Thus, the generalist physician went from adviser to “gatekeeper,” whose permission was needed for referrals to specialists and for tests. Naturally, patients hated this, and so did most of the physicians.

So we now find ourselves with a host of narrowly focused specialists, each vying to do the best and the most in his or her domain. They are closely allied with hospitals and medical and pharmaceutical manufacturers. There is no doubt that they do a great deal of good.

But there are underlying assumptions that cannot be ignored permanently. They are: (1) All services that provide any value to individual patients should be provided and (2) there is no trade-off between money and clinical usefulness in determining overall societal value. Perhaps a third assumption is that the money supply is infinite.

In other words, in health care, the kids can have it all - new shoes, new clothes and a weekend at Disneyland - because there is nobody to prioritize their needs. Patients want to be free. So do specialists. Primary phy-sicians don’t want to fight everyone. And we are all rightfully wary of top-down decision-making by government.

The answer to infinite spending or the alternative - rationing - is to find new ways to lower medical costs so that budgetary pressure doesn’t force us into more and more difficult dilemmas. So far, no one has found that answer.

Dr. Philip R. Alper is clinical professor of medicine emeritus at the University of California at San Francisco and former Robert Wesson Fellow at Stanford University’s Hoover Institution.

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