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Sunday, September 12, 2010

Politics and bending the health care cost curve

There are two pieces, one published in the New York Times today and another in the NEJM earlier in the week which are well worth reading. In addition, the authors of the respective pieces should read each others writings. I would love to see their comments. The piece in the NYT today is entitled "Is Newer Better? Not Always."

This Op-Ed points out what the author believes is an inherent problem with advances and innovation in treatment; it makes medical care more expensive. Is that me-too drug really worth the cost? Should we use this test on a particular population to screen for a particular disease?  This is by no means a novel question and in fact I have commented in this blog on more than one occasion, most recently I agree with the Op-Ed author that at least one of the challenges is the widespread lack of information to guide patients and physicians as to the outcomes from particular interventions and believe that investment in research to focus on outcomes is absolutely necessary. That is where our agreement ends.

This brings me to the second article, published in the NEJM and entitled "Lessons from the Mammography War".

This article deals with two big questions regarding screening women for breast cancer using memmography. The recommendations from the Preventative Medicine Task force was to change the recommendation for screening of women without risk factors to start at age 50 as opposed to age 40 and to do screening only every other year. Given the relative infrequency of breat cancer in the younger age group and the overwhelming number of false positve screens in the 40-50 year age group, it was not an unreasonable change to advocate. However, the firestorm of controversy generated two responses. First, it prompted all those who were political appointees involved in the process to run for cover. Second, it should make one think twice about the actual usefulness of outcomes data when it comes to allocation decisions.

Let me elaborate. Fast forward to the day when studies from the Institute for Comparative Effectiveness have been completed and you will get an idea of how this information will be treated if you look at the current day response to the mammography recommendations. It is simply not sufficient to do the outcomes research and expect this will be adequate to dictate best practices. It should be noted that the work put into studying mammography took literally decades and required the study of tens of thousands of women to examine the effect of screening. On the upside, these studies used an unambiguous endpoint, death. For many other expensive and prevalent interventions where benefit needs to be studied the endpoints are much more subtle.

Our desire for the product of outcomes research is that we can have THE ANSWER, unambiguous in black and white. Unfortunately, the answers will be much more nuanced and subtle, as evidenced by the results of mammography studies. Which brings us back to the quandary which face. Even with the best and hopefully increasingly better information on hand, who should be empowered to make decisions about allocation of scarce resources? The writers of the NYT Op-Ed piece suggest we are doing the right thing now and that it is simply a matter of sufficient courage and political will. This is nothing more than wishful thinking. Moving decisions regarding resource allocation of any type into the political realm guarantees that resources will be allocated in such a way to further political ends, generally short term political ends meaning the purchase of votes for the next election.

The lesson from the mammography wars is that data and science are not particularly politically compelling, despite the huge investment to garner them. When the primary mechanism for resource allocation is political, those with the largest potential immediate losses will invest substantial resources in the political realm to protect their turf. Hard data is not the fuel of politics, emotion and personal stories are and they will always trump data in the world of politics. Outcomes data will be like all of the items in that great store room pictured at the end of Indiana Jones and the Raiders of the Lost Arc, filed away for safe keeping and promptly foregotten.

The reality is as we move the allocation of resources in health care primarily into the realm of government, these resources will be allocated by increasingly political means. Like the data on mammography, what is hoped to be hard outcomes data will unfortunately come out not so hard and will not sway many (if any) in the predictable political fights over who should get what. It is the nature of politics and will always be the nature of politic. This type of conflict and behavior is inextricably linked to human nature and the desire for power and control.

We need to realize that certain types of problems are made worse when they are moved increasingly into the political realm. Resource allocation problems fall into this category. Allocation of scarce resources in health care will not be improved by making them more and more politically based. Attempts to create independent entities within government to influence or dictate specific health care decisions will always fail if the money spent is allocated through a political process.

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