Friday, December 11, 2009

Your Money or Your Wife

The following also appears on The Health Care Blog, at

http://www.thehealthcareblog.com/the_health_care_blog/2009/12/your-money-or-your-wife.html#more

Talk about perfect timing. Just as the last “death panel” falsettos fade into the droning no-government- takeover chorus, along come those “faceless government bureaucrats” from the U.S. Preventative Services Task Force to stop the music in the nation’s busy and profitable mammography suites.

No more breast self-exams or mammograms for low-risk women under 50; mammograms only every other year after the age of 50; nothing for any woman over 74. That was the thunderclap pronouncement from the acrobatically acronymic USPSTF, the dreaded “they” from the gub’mint that has the folks at Fox in full fulmination.

While the House and Senate grind their way through a few thousand pages of legislation and one more battle in the perennial abortion rights Holy War, this abrupt about-face in cancer screening is all people want to talk about, when we’re talking about health reform, in corporate strategy meetings. And the mix of incredulousness and anxiety in their voices speak volumes: this startling news from the health care technocracy does not affect their business; rather, it seems profoundly and directly to affect them personally, men and women alike.

Why so sudden and radical a reversal, they all want to know, in the war against cancer we have been winning for decades? And so I, swallowing hard, explain that the very smart people on HHS’ AHRQ’s USPSTF have discovered that all the effort and money dedicated to breast cancer screening for women under 50 actually saves only one life for every 1,904 women screened - while generating too many false positives, hundreds of unnecessary biopsies, and excessive anxiety.

It’s a big waste of money, “they” now tell us, and that certainly works for me, I say, swallowing hard again. I’m a male medical economist, after all, a hard-headed advocate of hard numbers, data-driven medicine, solid evidence, and efficiency, and I despise waste almost as much as I despise cancer itself.

Unless, of course, that one case in 1,904 happens to be my wife. Or my sister. Or my daughter. Would I, looking at that same study data from across her fresh grave, countenance the inconvenience and cost for those other 1,903 women? You’re damn right I would.

Not unlike the health insurance executives infamous for denying experimental treatment for everyone in their plans except their own family members, I know what I know is best for the group, for the public health, and for society – and to hell with that. What is best for the group has nothing to do with what is best for my best friend, even though she is low-risk and 46 years old. She should be screened, every year; and if her commercial health plan now has government-sanctioned cover fire not to pay for it, I will. Early detection is the single most important and durable factor in individual cancer survival, the epidemiology and economics of the group be damned.

You Are a Study Population of One

As for the incredulous and anxious colleagues who keep asking me to interpret the new guidelines, this is not an academic discussion for me. I have lost two friends, so far, to breast cancer, one on the eve of her 40th birthday. I have “raced for the cure.” And I have wept and prayed alongside nine other friends who, so far, have managed to survive the disease, and the horrific brutality of its treatment. (If the epidemiology of my social circle seems jinxed for a 47-year-old, know that its epicenter is a synagogue; when it comes to breast cancer, Jews really are the chosen people.) Truth to tell, I of course despise cancer more than I despise waste, to the point where I cannot think about the subject rationally, and I don’t think I’m an anomaly among even the most educated health policy wonks.

No, this is not a reasonable nor responsible position to take on this incendiary subject. But I suspect it is the position that most otherwise reasonable and responsible Americans would take. For proof, we need look no further than the nearest NICU waiting room. Our cultural belief in the sacrosanct, unlimited dollar-value of an individual life – oddly American and manifest no more plainly than in our bloated, screeching tort system - explains much about why U.S. health care costs what it does.

It also provides a picture-window into how most Americans confront the health care system today, and will continue to confront it tomorrow, nudged along either by piecemeal health services research or kicked down the road by concerted reform, with their employer’s money or with their own. If those faceless government bureaucrats say “no” - not unlike the faceless bureaucrats behind the managed care curtain have been trying to do for 20 years - then we’ll just buy what we want with our own money. This triangulated market dynamic is precisely how we ended up with “flexible spending accounts” and multi-tier drug formularies.

Of course, American women may not swallow the breast cancer screening revisionism as easily as we have all swallowed the bitter pills of aggressive pharmacy benefit management. The “women’s health amendment” rammed through the Senate right after the USPSTF announcement is Exhibit A of the intense fear that breast cancer strikes in the body politic. But that amendment, like mostly symbolic abortion coverage and the dreaded public option, is one more trading card in the most critical Congressional negotiation since the 1960s, so it is best not to count on it mitigating the effects of the new guidelines.

More likely, we should consider the new guidelines as one more big step down the path to a bifurcated health care system of medically necessary versus psychologically soothing, of what gets covered versus what gets turned into a cash business. Time, legislation and benefit design will tell.

Retail Radiology

In the meanwhile, the radiologists of America can relax: the new guidelines will not be followed by most women and most doctors. If the technocracy wins out over the politicians, mammograms for low-risk women under 50 will simply migrate into the “self-pay” category.

For proof, we need look no further than the success of the pharmaceutical industry at selling drugs that have been booted off formularies and out of benefit plans altogether. Mammograms for women in their 40s will join Botox, massage therapy, executive physicals, faith healing, herbal remedies, and all the other medical confections gobbled up by a neurotic, narcissistic, superstitious society addicted to medical care. As Voltaire once noted, “medicine’s role is to entertain us while nature takes it course.”

And that’s the junk, not a serious procedure that, until a few weeks ago, was a cornerstone of breast cancer prevention for women all the way down into their 30s. Ample conference speaking experience has taught me that if you want to turn a roomful of noisy, fidgeting, Blackberrying people stone cold quiet, just say “breast cancer.”

This may have more to do with our complex collective angst about breasts, sex, and motherhood, than with our baseline angst about cancer, disability and death. As most heterosexual males discover, often abruptly at a certain point in early adolescence, there is something quite remarkable about the female breast. With the possible exception of the heart, the breast is more freighted with mystery and meaning than any other feature of human anatomy. Associated unconsciously with our earliest and most nurturing (and paralyzing) memories of sustenance versus starvation - and associated consciously with our desirability (or desire), gender identification, and self-worth (or pride in our mate’s projected worth) - the female breast is electrified with pre-verbal psychological energy. If this were not true, plastic surgery would be a radically smaller and less lucrative business, and we would not recognize the visual landscape of the typical retail newsstand, where today breasts dominate not only shrink-wrapped porn, and not only music, entertainment, and men’s lifestyle magazines, but many of the women’s lifestyle magazines as well. This is the wellspring of the fury over the findings, the next-day “women’s health amendment,” and the outsized shock and curiosity by so many of my otherwise level-headed health care business colleagues.

If the women’s health amendment is traded away for a few more votes in the House, the new guidelines will stand; and consistent with what the crackpots fear most about “death panels,” the findings of the USPSTF will drive what is and isn’t covered by a standardized, subsidized, reform-hatched health plan – whether administered by an “exchange,” a private plan, a non-profit co-op, the OPM’s FEHBP, or Halliburton.

As mentioned earlier, those findings will also quickly find their way into commercial health insurance plans. “Consumer-driven health care” - roughly translated as “consumers pay more for health care” - has been highly effective at shifting demonstrably “wasteful” medical spending (e.g., the high marginal costs for only marginally better medications) from the employer/health insurer risk pool to the individual’s wallet, HRA, FSA, or HSA. And if it were not for the tax-advantaged status of all that spending, we could easily write it off as no-harm/no-foul to the macro-economy.

But radiology businesses learned years ago to direct-bill patients for procedures they did not need, with the introduction of “full body scans” marketed to otherwise healthy people, or what I like to refer to as “recreational MRIs.” The business strategies for marketing newly “unnecessary” mammograms will surely be no different.

Is This Any Way to Run a Government Conspiracy?

Beyond the inevitable market durability of a now discredited procedure for women under 50, there is something quite odd about the timing of the new breast cancer screening guidelines, given the fury the news was certain to unleash. If nothing else, choosing to open this Pandora’s box of empiricism versus emotion just as Congress is preparing its final push on health reform is proof positive that there is certainly no orchestrated conspiracy inside the Beltway to lull us into accepting a government takeover of health care. It would seem designed, actually, to have just the opposite effect, stirring up even the most ardent supporters of reform over what those “faceless government bureaucrats” want to take away from us first.

Better still, if you were a left-wing conspiracy theorist, you could make a good case that this whole thing is the work of somebody on the far right: they set up the USPSTF to announce these guidelines now, just in time to enrage the country at the health care technocracy and foil the Democrats’ grand designs. Get the federal government to un-do a generation’s vaguely comforting beliefs about breast cancer prevention at the precise moment that half of Congress is trying to convince the other half that health care is long overdue for some central planning, and see what happens.

Back in the real world, the announcement is also perfectly timed for open enrollment season for employee benefits and its sundry financial planning tasks. The smart money would bet that smart women in their 40s are Googling the cost of a mammogram and putting about that much extra into their health care spending accounts.

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2 comments:

  1. As usual, JD, an eloquent and fearless commentary on a hot-button issue. My counterpoint, filled with the same passion but leading to a different conclusion, is best illustrated by recounting a conversation with my wife from a few years ago.

    Kym is a 26-year Hodgkin's Lymphoma survivor and pursues health with the zeal of someone who will never go down without a fight. She reads everything she can get her hands on about fitness and nutrition - focusing on holistic approaches but also checking every box she can to ensure that anything penetrating this primary line of defense is caught early and treated aggressively.

    Kym started wearing a Live Strong type band supporting Hodgkin's research and asked that I do the same. I wore it for a while, but stopped, but didn't share my reasons. One night, she confronted me about it - she saw my reluctance to wear it as a lack of support for her personal quest for health. This was when the floodwaters broke through as I choked out my defense: I can't focus on this one disease because I CANNOT KNOW what will get you!

    As a Hodgkin's survivor and someone whose treatment included a splenectomy and aggressive radiation therapy (back before the notion of targeted or conformal therapy had been added to the radiologist's lexicon), Kym is at risk for melanoma, breast cancer, heart disease... with a Hodgkin's recurrence far down the list.

    Yes, it is brutally hard to look at the scientific evidence and not want to NIMBY-ly cry out, "Not in my benefit coverage!" Our most common reflex as Americans is to want to ACT - intervene even when it could kill us and when watchful waiting is the safer and more therapeutically sound approach. But we are talking here about population-based decisions and this IS the level at which we need to make general policy recommendations - always with the caveat that individual factors be considered.

    One of our greatest sins in medicine is that we go for the quick-fix intervention by focusing on the organ, on the single pathogen, on the most obvious manifestation of a problem. Instead, we should be employing what industries have been leveraging more and more - LEAN and Six Sigma process improvement approaches that analyze root causes and address those.

    If we're going to fight these recommendations, let's look at the science and critique that if warranted. Since we absolutely ration healthcare today, let's at least move to a more rational rationing. As you said, people will still spend the money going after "recreational" or fear-assuaging screenings, evidence be damned. That's fine, but don't force it as a national coverage policy. We need to spend our limited resources on the places that will bring us the greatest benefit. Focusing all our defenses on the front gates just leaves us vulnerable to a thousand other fronts.

    Instead of buying mammograms for your friends, think about using the money to them gift certificates to Whole Foods and nutrition classes - you'll likely do more to protect them from breast cancer and many other threats besides. The question is, can you look past the less exciting, less action-packed nature of this intervention and see that it is filled with even greater passion than the nuclear option because it looks past the emotional, gut response and, with steely resolve, focuses on the deeper need.

    This, to me, is love in action.

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