The Bang Of Your Medical Buck

doctor What good are mammograms?

Is it wise policy to encourage Americans who already spend more than $8 billion annually on these tests to get more?  And why does Obamacare, which generally favors evidence-based medicine, mandate this service despite new research suggesting mammograms don’t save lives.

The latest chapter of this heated debate provides a window into the complex and tortured relationship between politics, medicine and economics, where there are no clear or easy answers.  While it is true that the players often behave selfishly, that’s normal human behavior peripheral to the question of how provide the healthcare we need – often less than what we’re now getting – at a price we can afford.

From the start, we have difficulty dealing with the tentative nature of science.  That often means that by the time a scientific finding becomes compelling enough to be translated into policy, there may be a contrary scientific conclusion launching.  In the women’s health area the ongoing debate about estrogen therapy is a case in point.

While the latest study suggests that mammograms don’t save lives, that doesn’t preclude the possibility of a new treatment for early stage cancers that could upset these findings.

Despite our discomfort with a public debate, our healthcare system is constantly asked what treatments are worth paying for.  Until we find a health fairy who’ll simply pay all our bills, that means dollars spent keeping terminal patients alive a few more weeks are dollars that cannot be spent on healthcare for children.  If we spend more money on cancer research, there will be less for diabetes.

It may be satisfying to fantasize about a system where priorities were set so as to maximize the bang for our medical buck, but that’s not about to happen.  Even if we had the technical skill to create such a system, our political system would reject it.   So it was unsurprising to see that the initial New York Times report on mammograms elicited reader responses about how valuable they were because a friend or relative avoided dying of cancer because of them.

Assuming these stories are correct, the question remains as to how many such incidents are required to justify a multibillion dollar investment.  If a hundred annual deaths are avoided, is that a good investment?  What if the number is ten – or three?

The situation is further complicated by gender politics.  Health legislation today tends to skew toward women’s because of realization that the focus until a few decades ago was on research and diseases that emphasized problems men confront.  Since then, there have been efforts to redress that imbalance.

Breast cancer is central to that debate, at least partly because the strategy until the 1950s involved aggressive disfigurement (The Emperor of All Maladies, the excellent and definitive biography of cancer construes the since discredited surgical theory as “The more you cut, the more you cure.”) of patients – always women – by surgeons (nearly always men) in procedures that often did little good.

Income disparity confuses things further.   One can imagine a healthcare system that provided certain core services to all while allowing the rich to purchase premium service.  The ability of some to pay for an annual – or even semi-annual – physical, concierge physician services or cosmetic plastic surgery wouldn’t require that such services be available to all, irrespective of their ability to pay.

That doesn’t seem to be in the cards.   Many liberals have long insisted that the same menu of services be available to all, irrespective of efficacy.  In other words, if rich women pay for annual but virtually useless mammograms, poor women should have equal access to them lest we create a two-tiered discriminatory system.

Within Obamacare are several initiatives aimed at getting us to think about these questions, but there’s no reason to anticipate answers anytime soon.  Ultimately, they’re much tougher than the computer glitches getting so much current attention. punditwire

For 16 years, Jim Jaffe worked for House Democrats who served on the Ways and Means Committee, apprenticing with Representatives Green, Gibbons and Gephardt before working for Chairman Dan Rostenkowski.

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  • Maggie Mahar


    The questions you raise here are far more important than the
    (disappearing) computer glitches, As you suggest, they are far less important. But it’s much easier to write about computer glitches than it is to think about–and write about- -the ethical and economic questions that healthcare reform raises.

    On mammograms: the biggest problem is that mammograms produce so many “false positives”. A woman is told she has breast cancer when, in fact, the tiny tumor would never develop (“cancer in situ”), Nevertheless, she undergoes a biopsy, and in some cases a lumpectomy (or, if she is really scared, or her doctor is very aggressive, a mastectomy.)

    I would urge everyone to read Clifton Leaf’s seminal new book which describes “Why We Are Losing the War on Cancer.” (Jim, I think that you, in particular, would enjoy this extremely intelligent book.)

    As Leaf points out, despite mammograms the number of woman per 100,000 who die of breast cancer has increased since 1970 (when we declared a war on cancer.( There could be many reasons (environmental causes come to mind), but the fact is, as he points out, when it comes to preventing deaths, mammograms have been nearly useless. We pretend that a woman’s life was “saved” by mammogram if she survives 5 years after her diagnosis. But over the years, 5-year survival rates have improved only because more women go for mammograms more often, and so their cancer is detected earlier..

    But they die of breast cancer at the same age that they would have died if they hadn’t had the mammogram.,

    Without the test they might have discovered the”lump” 2 years before it killed them. This means that the years of fear, worry, and painful treatments would have been reduced by 3 years.

    Jim, you write: “It may be satisfying to fantasize about a system where priorities were set so as to maximize the bang for our medical buck, but that’s not about to happen.”

    Here I would tend to disagree, though perhaps I’m just disagreeing regarding “about to happen,.”

    It won’t happen tomorrow–or this year.

    But see what Peter Ortzag says here about the “Better Value, Lower Cost” bill now in Congress.

    It’s actually a bi-partisan bill.

    Will it pass? I have no idea. Maybe enough Republicans and Democrats will realize that it would be a good idea to pass a sensible bi-partisan piece of legislation.

    Maybe not.

    But the bill does crystallize where reform is headed. It tells us what
    is already happening on the ground –as insurers hold providers
    responsible for the care they provide.