Last week I illustrated how the last century was quite a good one for health. This is largely due to advances in public health, though there is at least one bright spot in the area of medical science: the treatment of cardiovascular disease. There are a few other bright spots too; along with cardiovascular treatments, David Cutler points to early life care and mental health treatment as exemplars. Over the last 50 years, however, whatever advancement has been achieved by medical science, it has come at a very high cost. It would be hard to call the field “efficient.”
Phillip Longman makes that point in Best Care Anywhere, a quick read covering a great deal of territory.
According to Harvard health-care economist David M. Cutler, in 1960 the average American 65 or older consumed an inflation-adjusted $11,495 in health care during his or her remaining lifetime. By 2000, that number had jumped to $147,054. Yet despite this elevenfold increase in health-care spending per senior, the resulting gain in life expectancy was a mere 1.7 years. Measured by its “rate of return,” or the extra years of human life produced per health-care dollar spent, American medicine is amazingly unproductive and inefficient.
Why such inefficiency? In large part that’s what Longman’s book is about. Focusing on the minority of patients accounting for the majority of cost, he writes,
Medical textbooks are silent about what constitutes appropriate care for patients with many different illnesses, particularly for those nearing the end of life. For example, medical textbooks offer no evidence-based clinical guidelines for how often doctors should schedule such patients for return visits, when they should be hospitalized or admitted to intensive care, or what palliative care they should receive. Nor do medical textbooks offer clear guidelines, grounded in science, about when a doctor should refer a patient suffering from a specific condition to a specialist, much less when it is appropriate to order a diagnostic or imaging test.
The questions of whether and how physicians might enhance delivery of more efficient care were raised to high profile by the inclusion of the following in the updated edition of the American College of Physicians’ (ACPs’) ethics manual (pdf):
Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. [...]
Physicians, patient advocates, insurers, and payers [...] should base allocations on medical need, efﬁcacy, cost-effectiveness, and proper distribution of beneﬁts and burdens in society.
Aaron appropriately pushed back against the notion that the physician’s office is the right place for cost-effectiveness to enter the equation, though it is not clear that’s what the ACP intended. (It is clear it could be read, or misinterpreted, that way.) In a brief and incisive post, Bill Gardner interpreted the ACPs’ call for “parsimonious” care in the context of scarce resources and a goal of universal coverage.
But if you want limits on spending, and you want at least an approximation of universal coverage, then you need a technological and organizational revolution in health care that will increase the productivity of the medical workforce and reduce the price of good care. And I have a kind of blind faith that this will happen. But until that year of jubilee, we have to accept that insurance cannot cover everything.
Actually, in large part, that’s what the jubilee would be: guidance about what should and should not be covered with collective (public or premium-based) funds. (Or, in more nuanced form, what value-based insurance looks like in detail.) Naturally, when insurance stops covering things that don’t work (or for whom they don’t work), as demonstrated by sound research, physicians will do less of those things and more of the things we should want them to do, providing more effective and efficient care. That’s the source of higher productivity we’re waiting for. In with the good, out with the bad.
But, before we have any right to faith in a forthcoming jubilee, we need the research. In JAMA, Vinay Prasad, Adam Cifu, and John Ioannidis say we’re not getting it, even when we try.
There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. [...] The research community performs studies of modest incremental value without even knowing whether the basic standards of care are appropriate.
This is an important, systemic failure because, as Prasad, Cifu, and Ioannidis write,
First, patients who undergo the therapy during the years [untested and inappropriate, yet standard, care] is in favor receive all the risk of treatment and, ultimately, no real benefit. Second, contradicting studies do not immediately force a change in practice; the contradicted practice continues for years. Third, contradiction of mainstream practices undermines trust in the medical system.
It’s hard not to despair. Much of our efforts in medical care and even well-meaning (or not) medical research are squandered, or, if not quite that, then not directed at the lowest hanging fruit. We don’t just lack the right research, we seem to lack the right research agenda or framework that guides us to that fruit. At the same time, it’s not evident to me we can’t know where to look for that fruit or, at least, narrow the possibilities. I’ll come back to this idea.
For now, the upside is that there are loads of ways to make the US health system more efficient, even though we may not be able to identify them all right now. By ceasing to make the type of systemic errors described above — by shifting from an eminence based to an evidence based system of care — we can do better. Thanks to investments in public health and a few veins of evidence-based medicine, the last century was quite good despite the systemic errors made in the medical science enterprise. The next could be better still, but only if we change our ways.