This kind of thing really has to stop

I missed the debate last night, because I was having dinner with a group of people I’m going to talk to today about health care policy. I’m sorry I couldn’t see it, because there seems to have been a lot of talk on health care reform. Most of it we’ve seen before, but I just can’t ignore this:

Earlier in the debate, Mr. Gingrich condemned a proposal of a government task force to end routine tests for prostate cancer in men, saying it would cause deaths. But the panel that made the recommendation concluded that the test itself had caused deaths and injuries unnecessarily.

Mr. Gingrich was referring to a draft recommendation of the United States Preventive Services Task Force, which concluded after five clinical trials that healthy men should no longer receive a P.S.A. blood test to screen for prostate cancer because the test does not save lives over all and often leads to treatments causing pain, impotence and incontinence for many.

This is the mammograms all over again. So much so, that I can just lift parts of prior posts. Let’s start with this:

The USPSTF is not a political organization.  They aren’t an advocacy organization, or even a policy making organization.  They are, “[a]n independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.”

Mr. Gingrich also asserted that there are no medical specialists on the panel. That’s not true. He said that the panel would mean the end of testing for prostate cancer. That’s also not true, as legislation already mandates coverage for the tests no matter what the USPSTF says. He also says that this validates Gov. Palin’s claims that death panels exist. That’s the lie of the year.

We have to be able to have rational conversations about relative benefits and harms. We have to be able to talk about areas where we can stop doing things, especially when the things that cost money are doing harm:

As the P.S.A. test has grown in popularity, the devastating consequences of the biopsies and treatments that often flow from the test have become increasingly apparent. From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both. As a result of these complications, the man who developed the test, Dr. Richard J. Ablin, has called its widespread use a “public health disaster.”

One in six men in the United States will eventually be found to have prostate cancer, making it the second most common form of cancer in men after skin cancer. An estimated32,050 men died of prostate cancer last year and 217,730 men received the diagnosis. The disease is rare before age 50, and most deaths occur after age 75.

Not knowing what is going on with one’s prostate may be the best course, since few men live happily with the knowledge that one of their organs is cancerous. Autopsy studies show that a third of men ages 40 to 60 have prostate cancer, a share that grows to three-fourths after age 85.

Prostate screening wasn’t outlawed.  It wasn’t taken away.  No one’s insurance stopped covering it. This was a reasoned statement that it’s not clear it does more good than harm and that we need to reconsider its use:

“Unfortunately, the evidence now shows that this test does not save men’s lives,” said Dr. Virginia Moyer, a professor ofpediatrics at Baylor College of Medicine and chairwoman of the task force. “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.”

I’ll let me summarize:

How can we decide what works and what doesn’t?  How can we decide what can be cut? That’s why we need comparative effectiveness research.  That’s why we need bodies like the USPSTF.  Independent organizations made up of people who understand the research and can inform us how some things compare to others.  They’re not perfect, but they are transparent, accountable, and public.

We so often act as if everything in medicine is an unequivocal benefit.  That’s simply not the case.  Everything has harms as well.  Ideally, the benefits outweigh the harms.  Sometimes, however, that’s not the case.  And sometimes, in the real world, cost is a harm.

There simply isn’t an unlimited amount of money in the budget.  Each dollar we spend on stuff that doesn’t work is a dollar we can’t spend on stuff that does.  Legitimate care is denied every day.  Ideally, it should be denied when it doesn’t work, or isn’t providing bang for the buck.

How are we to prioritize what to pay for?  That’s an excellent question.  I don’t necessarily have the answer.  But we need to find an answer.  Putting our heads in the sand and pretending that we will never need to make these decisions will result in economic ruin.  Saying that we need to cut costs and then declaring that any attempt to find places we can cut costs is rationing – sometimes even saying those two statements almost simultaneously – is not only hypocritical, it’s also dangerous…

Understand – most of the “waste” in health care comes from just this sort of stuff.  It’s not easy to identify, and even harder to cut.  It won’t be universally popular, and it won’t win anyone political acclaim.  But it needs to be discussed and debated. Someone is always going to be upset at cuts in spending.  They can’t come from nothing.

If we’re not willing even to entertain a discussion of cuts, though, we’re doomed.  If we declare any recommendation to reduce expenditures as “rationing” or “unethical”, then we will go bankrupt.  We need leaders willing to host a rational discussion on health care costs free from partisan rhetoric, or we might as well close up shop now.

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