Health Care Reform Update: Science or Rationing?
by Alta Price, M.D.Health care reform proposals to encourage the scientific study of medical testing or medical treatments will help improve our health and lower costs. The anti-reform myth that comparative effectiveness research is code for rationing is ridiculous. I guess it is just more evidence that the GOP doesn’t have much understanding of science – whether it is evolution, climate change, or medical research.
Although I think medicine is a great profession, it is not a very scientific discipline. I always loved science, which is why I specialized in pathology, the study of disease. Pathology is about diagnosis – including laboratory testing – which appeals to me more than the treatment side, which I consider the “art” of medicine. As a pathologist, I know a thing or two about the science of screening for disease. And I spend a lot of time looking at breast biopsies and cervical biopsies. So this whole brouhaha about recommendations for mammography and pap smears is right up my alley. In case you missed it, here is a New York Times article about the issue, “Screening debate reveals culture clash in medicine”.
Doctors make all sorts of recommendations to their patients for all sorts of reasons. Sometimes scientific studies show that our recommendations are not helpful. In fact, they could cause harm. A recent case to illustrate this point is treating post-menopausal women with hormone replacement therapy. Based on what we understood at the time, we thought hormone replacement would decrease women’s risk of heart attacks and strokes, as well as protect against dementia. We weren’t sure if it would increase the risk of breast cancer. And we knew it could cause uterine cancer. I only became aware recently of the role Wyeth played in getting favorable studies published in the medical literature to promote the use of hormones in post-menopausal women. Wyeth made literally billions of dollars every year selling Premarin and Prempro for this purpose. When a huge federal study came out in 2002, it turned out that hormone replacement therapy increased a woman’s risk of heart attack, stroke, dementia, and breast cancer. In fact, when everyone stopped taking hormones, breast cancer rates decreased within a few years. This is a perfect example of scientific research funded by the federal government improving our health and lowering costs.
Likewise, many doctors feel it makes sense to screen women with mammograms starting at the age of 40. As it turns out, when the U.S. Preventive Services Task Force looked at the scientific research they found that annual mammograms for women between the age of 40 and 49 do not result in a significant decrease in deaths from breast cancer. In other words, the women in the screened group were just as likely to die of breast cancer as the women in the non-screened group. For women 50-69, screening decreased the rate of breast cancer deaths. Those are the facts.
The next question is what do you do with those facts? Well, one way to improve a screening test is to screen a population more likely to have the disease. In fact, that is why mammograms help women 50-69 – they are more likely to get breast cancer. So if you could identify which women age 40-49 are more likely to get breast cancer, it is possible that subset of women will benefit from regular mammograms. Interestingly, if you go to the actual recommendations of the U.S. Preventive Services Task Force, that is what they say (scroll down to Clinical Considerations). And after all the hysteria, I think I’ll quote at length:
• The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (e.g., false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70.
• Women who are at increased risk for breast cancer (e.g., those with a family history of breast cancer in a mother or sister, a previous breast biopsy revealing atypical hyperplasia, or first childbirth after age 30) are more likely to benefit from regular mammography than women at lower risk. The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause.
Notice also that it requires a doctor to explain to the woman in the 40-49 age range the benefits and risks of mammography, and to help her decide whether she should be screened. In a society where not everyone has a primary care doctor, it may make more sense just to screen all women starting at age 40. Hopefully, health care reform will enable everyone to have access to a doctor so they can receive personalized care right for them.
So what is the relationship between rationing and scientific research into best clinical practices? Well, as far as government-run programs like Medicare, there is very little relationship. A doctor and a patient are free to do pretty much whatever they want, whether it is scientifically sound or not, and Medicare will pay for it. By the way, I am not saying this is a good thing! But again, that is the way it is now. Also, nothing in the health care reform bills in Congress would change the fact that doctors and patients in Medicare (as well as in the new public plan) are free to do whatever they please. In fact, one reason the Congressional Budget Office thinks premiums might actually be higher in the public plan is because the government plan “would probably engage in less management of utilization by its enrollees” – i.e., the plan would pay even for testing or treatments that were not based upon good science.
The situation is different with private insurance companies. They are much more likely to deny payments for testing or treatments that have no scientific support. I would worry much more about private insurers taking the new recommendations too far and deciding not to pay for mammograms for women in their 40’s. You don’t see the anti-reformers having hysterics about private insurers rationing care based on scientific research, even though under the current system and health care reform proposals before Congress right now, if medical research is going to be misused for rationing, it will be in the private sector.
Have a safe and happy Thanksgiving. As a special service, Families U.S.A. has provided this handy “Talking Turkey” guide for those of you spending the holidays with relatives who watch too much Faux News!
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