Any debate discussion involves establishing premises. Hopefully, the premises are accepted by all parties and the subsequent discussion involves attempts to build a logic chain from them. If a premise is flawed, then any subsequent logic chain whether accurately constructed or not will be questionable. When a premise is not accepted by all parties in a discussion, that discussion will likely degenerate into arguments making little progress. As in any debate, before engaging in argument, it is important to assess the premises.
One premise in the health care cost debate in the United States is “Preventive Care is less costly than waiting for a disease to emerge and then treating it.” Many accept this premise and, upon it, assert that less costly health care will involve screening for disease, immunizations, and, in some cases, surgical intervention in seemingly healthy individuals. For some time now, some of us have questioned whether this premise is accurate. Regardless of your position on the Affordable Care Act (ACA), this premise deserves deeper analysis than simply accepting it. There are several components that supposedly support this premise including the following paragraphs.
Keep people out of the emergency room will allow for less expensive care. Estimates are that between 20 and 55 million US residents do not have sufficient health care coverage to seek primary care in a private setting so they seek care in emergency rooms. This means that care is very expensive (several thousand dollars in the ER versus one to two hundred in a primary care office). It is also fragmented (ER staff tend to address only the condition for which a patient presents and not the total health of that person thus chest pain will be worked up and treated but no attention paid to the severe arthritis or obesity). Cost effective analysis of providing primary care in an office rather than in an ER is fraught with variables that cannot be controlled. If all those underserved persons descend upon existing primary care facilities, there will be a major expansion in cost of primary care (for example 30 million persons at $200 a year would cost $6 billion). How many ER visits would be obviated? In my opinion, the benefits of primary care in a primary care office are clear cut and worth any increase in overall cost that may occur. This support of the premise appears to be correct in my opinion.
Cancer Screening When the Pap smear was developed, this became a “gold standard” of preventive care for women. The test was inexpensive, non invasive, quite accurate (not, however 100 percent accurate), and could lead to relatively inexpensive, effective care that would cure what was otherwise a devastating and fatal cancer. Virtually all physicians accepted this preventive care as a less costly form of care than waiting for the cancer to occur and treating it. The keys to this success were an inexpensive test leading to an effective and inexpensive curative procedure for a predictably deadly disease. Soon, other cancer screens were added and touted as being similarly successful. Chest xrays in smokers, mammagrams, PSA blood tests, stool blood tests, annual skin exams, and others. Several aspects of these tests led to failure in both cost effectiveness and disease management lack of efficacy:
1. If positive, the therapeutic intervention was not a less invasive or less costly means of treatment. For example, a positive mammagram is treated in pretty much the same manner as a mass felt in the breast. Unless one can prove that that treatment is more efficacious when initiated early, there is no advantage from the screening tests.
2. False positives lead to expensive and, potentially dangerous confirmation tests. For example, a positive stool blood test can result from several causes other than cancer. Thus the finding must be followed by colon xrays and/or colonoscopy. These are costly and may not be definitive. This screening test becomes costly and entails significant chance of complications by the time false positives are evaluated.
3. Cost effectiveness of the test requires that the total cost of screening, treating false positives, and treating true positives be less than waiting for the disease to emerge and treating it. Several studies have found data to not support this being present for stool blood tests, chest xrays for smokers, PSA, and several other “preventive” studies.
4. In some cases, there is evidence that “early” discovery has not led to better survival from the disease being screened. For example, mammagrams in 65 year old women do not affect life expectancy. Mammagrams in 40 to 55 year old women do appear to provide a modest improvement in life expectancy for that group. This does not mean that the overall cost of care is less, even then. That analysis becomes extremely complex and findings are easily affected by the bias of the “investigator.
So, the bottom line is that screening for cancer is not particularly cost effective except in a few, specific cases (such as the Pap smear) or in high risk populations (e.g., colonoscopy every five years for persons with ulcerative colitis). The premise is only occasionally correct when applied to screening. Despite scientific evidence calling into question cost effectiveness and efficacy of such screening, most persons advocating heath care reform include the “advantages” to be achieved from increased screening as a preventive measure.
Immunization Care. Immunizing against diseases can be effective in preventing that disease and, therefore obviate completely cost of treating the disease. Success has been seen through complete eradication of small pox and near complete eradication of childhood scourges such as measles, chicken pox, diphtheria, and polio. In some cases, success has been such that some now question whether the risk of the immunizations exceeds the risk of the diseases. I have made my view clear on this elsewhere so will not go into it here except to say that death or disability from these diseases is inexcusable in a modern society. Recently, new immunization technology has emerged making it possible that there may be a much larger group of diseases that can be prevented with this technology. In the interest of full disclosure, I will state that I have invested part of my IRA in a company that is working on immunization technology. So far, my investment has only lost about 70 percent of its initial investment. Some problems with assumption of cost effectiveness for new vaccination interventions:
1. Again, cancer of the cervix was one of the first. Cancer of the cervix is highly related to infection by a group of viruses. Immunization for those viruses prevents subsequent infection making it likely that the cancer will be prevented. The cost issue seems to be significant. This is an expensive vaccine. The Pap smear is relatively inexpensive. Additionally, taking the vaccine does not obviate need for periodic Pap (or equivalent) testing. It will be difficult to establish that receiving this vaccine will save overall cost versus continuing classical management. I am not up to the math of estimating cost effectiveness of these vaccines. However, if the disease might affect 1 percent of the population at a cost of $500,000 per case and the vaccine costs $250 per person, the cost benefit of immunizing would be $425,000 per case. However, cervical cancer affects a smaller group than that and, with early detection, costs a lot less to treat. My best guess is that the cost effectiveness is close to a wash. There is evidence that some oral cancers may be preventable with the same vaccine which would add to the cost effectiveness of the vaccine.
2. Immunizing for hepatitis B can prevent that illness. The vaccine is relatively expensive. However, hepatitis B is a potentially lethal illness and, in its chronic form can lead to liver cancer. The cost of treating hepatitis and liver cancer are very high and, it appears likely that this vaccine is cost effective. I have not seen any analyses of that so cannot prove it to be accurate. My “intuition” sense tells me that this is a valuable vaccine and I have received it.
3. In the pipeline vaccines include several for hepatitis C, several for HIV, malaria, and a host of other illnesses. It appears very likely that, in the future, health care will need to assess persons for risk of incurring illnesses and deciding if the risk and cost of vaccines are worth the investment. For example, malaria vaccine would not be recommended for persons living their entire life in the continental US. Much like cancer screening, vaccination will often be directed toward susceptible populations rather than universal. HIV vaccine would be cost effective for persons with potential for multiple sex partners but not for persons likely to be celibate or lifelong monogamous (yes, there are a few of these still in the world).
Screening for Early Detection. The “honored” annual physical examination. Included here are blood pressure, pulse, weight, blood sugar, urine analysis, cholesterol, and a host of other tests. Numerous investigators have questioned the alleged value of these procedures. Certainly, some are of minimal to no benefit, at least in a doctor’s office setting. I won’t go into the details of cost analysis here other than to agree with those who assert that an “annual physical” is pretty much a waste of resources. Weight monitoring can and should be done by ones self. It should also be part of every visit to a physician’s office. BP measurements are readily available at multiple sites for no cost (accuracy may be an issue) and should be taken at every visit to a physician’s office whatever the specialty or reason for the visit. Blood sugar measurements are probably important if you are more than 25 percent overweight and/or have a family history of type II diabetes mellitus. The list of diseases for which screening is recommended continues to expand at a rate exceeding capability of establishing or disproving cost effectiveness. Screening for depression, dementia, autism spectrum disorder, vision (in children), hearing, coronary artery disease, chronic obstructive pulmonary disease, and so forth are all possible. Given a three or four hour primary care visit, your physician and staff can screen for all of these. You tell, me, is it worth the investment?
Screening for congenital diseases. A simple blood test at birth can screen for a number of diseases that are rare but have devastating impact on children afflicted with them. Some of these can be treated with diet management (glycogen storage disease), others are treated with medication (hypothyroidism), and other modalities. Congenital hypothyroidism is a special case in that treatment, ideally is initiated prior to birth since there is evidence that afflicted children will have lower IQ than normal if only treated after birth. I do not know if there is yet a prenatal screen at this point in time. Recently, genetic testing of fetal blood in the mother’s blood stream (i.e., screening for genetic disease by a blood test of the mother) has become possible. At this time, that testing is prohibitively expensive. However, genetic analysis methodology is evolving rapidly enought that it seems likely that such testing will become affordable within ten or fewer years. The question will then become, “is it cost effective to diagnose genetic conditions prior to birth?” If the answer is no, it is not cost effective, there will still remain the question of “Is it of sufficient value to justify the investment for such testing?” Here, my best guess is that identifying these illnesses at birth or earlier can lead to relatively inexpensive and effective treatment thus saving millions of dollars per person in life long care and loss of productive livelihood.
Summary. There are numerous cases in which “preventive” care is neither less expensive nor more efficacious than routine management of illnesses as they emerge. There are, however, several instances in which “preventive” care is both cost effective and efficacious. Many of these do not necessarily involve health care as such. Pasteurizing milk helped stop intestinal tuberculosis as well as some other conditions. Careful sterilizing of preserved foods has made botulism a rare disorder. Refrigeration has led to significant cut in salt consumption and may be the single most effective prevention of high blood pressure implemented. Most industries have dynamic safety programs in recognition that injuries prevented save money and resources. On the medical intervention side, few US citizens have ever seen tetanus, or for that matter, polio, small pox, whooping cough, and a host of other illnesses due to effective vaccinations. In my humble opinion, vaccination for those diseases clearly preventable on a cost effective basis should be made universally available at minimal to no cost. These include polio, measles, whooping cough, tetanus, diphtheria, hepatitis B, and a few others. When I was in practice in New Mexico, the state provided childhood immunizations at no charge through county nurses. As a physician, I sent all my patients to that source and simply counseled them how important the shots were and monitored that they were obtained.
This is a long discussion of whether Preventive Care is cost effective and therefore should be included in health care coverage. My answer is that the instances in which preventive care is clearly cost effective are limited. The exceptions are severe enough that they make this particular premise not valid in affirming the prevention clauses in the ACA as leading to significant savings.
I am mostly in agreement. Prostate cancer is another one where early diagnosis is not really leading to improved mortality. However, I would not look at just dollars spent on medical care. I would also add in QALY type measures to see if we are improving quality of life and/or longevity.
Steve
Your premise SEEMS to be predicated on the view that healthcare reform must be based on “improving/expanding care for all,” and NOT primarily cutting costs/expenditures.
That is obviously NOT the prime consideration of the systems American reformers have championed.
England’s NHS has primarily a rationing/cost-cutting agenda. It’s been excoriated for that mainly because it is STILL too expensive even with widespread rationing of care. (SEE:
That’s why Hong Kong looking at BOTH the UK & the USA said, “All that can be learned from either is what NOT to do.” (SEE Fareed Zakaria’s GPS look at healthcare around the world at
In the USA healthcare reform was first initiated and bankrolled by Corporations back in the 1970s and 80′s) who RIGHTLY want to “get out from under this burden” and become more globally competitive. That’s a sound strategy on their part, as when America’s businesses become more competitive, America’s labor also becomes more attractive (more cost-efficient) to foreign investors and America’s economy can grow more efficiently.
Now, while it’s understandable that self-serving physicians will lobby for the MOST healthcare for the MOST people – as we ALL argue for more of what benefits ourselves, – (I’ve opposed the “fire-proof cigarette” and cuts in Fire budgets for the some of the very SAME reasons), BUT that’s usually impractical and due to our own innate short-sightedness.
Like England, we simply CANNOT give ALL Americans gold-plated/best quality healthcare. We NEED to have a public/universal healthcare that either provides ONLY a bare minimum of care (4 to perhaps 6 visits per year and up to $10K/year in expenditures per patient NOT “rolled-over”) OR, like the NHS severely ration care based on age, severity of illness, cost of treatment relative to outcome, etc. Those are the options given our current focus.
Hong Kong (the freest economy on earth) has looked at another route, as they’ve chosen to take healthcare completely OUT of the marketplace and basically place it under government control – bureaucrats will dictate which treatments are necessary, acceptable and under what conditions, what physicians can charge, how much tests will cost, etc. It’s a very bold strategy and given healthcare’s inability to be regulated by the marketplace (people rarely plan and save for catastrophic health issues), it MIGHT BE a better alternative than our own bland “public option.”
Unfortunately, the “Tragedy of the Commons” makes free/government-sponsored healthcare impossible. When given free without restrictions/rationing, it immediately “breaks the bank.”
Bolder steps seem necessary and Hong Kong’s seems to be one of the boldest.
I posited no personal premise. Instead, I attempted a partial analysis of the premise posited by many involved in health care. Specifically, “One premise in the health care cost debate in the United States is “Preventive Care is less costly than waiting for a disease to emerge and then treating it.” My conclusion is that this is only a true premise in relatively limited areas and not in the generally accepted meaning that “preventive care is always cheaper and better.”
I have no idea how Hong Kong addresses preventive care in their system. Perhaps you could provide some information on that since you have frequently indicated admiration for their system.
No, my objection is that NO ONE (especially NO ONE on the Left, but pretty much no one) is advancing an agenda such as yours.
Moreover, Preventive Care is NOT cheaper.
Dr Eric Braverman is a leader in intensive preventive care and anti-aging and his treatments (which often include HRT & HGH treatments) are somewhat pricey – $25,000 for an executive plan and $10,000 for a the more modest plan. On the plus side he runs a battery of tests that is second to none, including “brain mapping” and measuring various neurotransmitter levels.
I’ve seen the very positive effects that both HRT and especially HGH treatments can do, BUT these are very expensive options. Ideally EVERYONE should have access to these as they get older and aging SHOULD BE treated as a disease, BUT we simply can’t afford to provide that at “taxpayer expense.”
Again, the problem with “free care” is that it doesn’t exist. What passes for “free care,” is very short on free and often even less likely to be real “care.” Moreover, an emphasis on pre-emptive care (pre-cancer screenings, etc) STILL falls victim to the “tragedy of the Commons” – overuse of “free” commodities by the general public, resulting in overworked healthcare staff and ponderous expenses that can’t be sustained.
Which is why the NHS has become so addicted to severe rationing.
Hong Kong is, according to Fareed Zakaria (who I linked to for you) still developing its plan, but it appears intent on taking healthcare completely out of the marketplace. While Zakaria may be too much of a “global citizen” and too little of a “devoted American” for our tastes, he did an excellent look at healthcare systems around the world, available online at the link above.
“… no one) is advancing an agenda such as yours.” Again, I am NOT proposing an agenda. I wrote this piece in order to analyze some of the aspects of cost effectiveness and clinical effectiveness of preventive care.
You have introduced another of those in the form of HRT and HGH treatment for prevention of aging and preservation of health. Dr Braverman is only one of the more prominent advocates of this treatment. Let’s look at the data:
Hormone replacement therapy (HRT) for women was a long time standard for management of women entering menopause. Inexpensive and apparently safe, it was advocated for preventing osteoporosis, heart disease, hot flashes, loss of sexual capacity, and other conditions. Over the years, its effectiveness in all of these except for prevention of hot flashes and vaginal dryness has been found either ineffective or questionable. In addition, several complications and significant adverse effects have been found and others seem possible. See http://www.mayoclinic.com/health/hormone-therapy/WO00046/ for a nice summary by the Mayo Clinic written in non technical terminology. Most physicians no longer routinely prescribe HRT for women.
HRT for men has become a recent popular procedure. Many men have gradually lowering testosterone along with aging. Giving HRT for men has been reputed to increase muscle mass, protect from aging, improve sexual desire and performance, and other benefits. The ads you see on TV do not mention possible growth stimulation for prostate cancer, breast enlargement, possible arteriosclerosis, and other side effects. See http://www.health.harvard.edu/newsweek/Hormone-replacement-the-male-version.htm for a balanced review of this. Interestingly, HRT for men appears to be possibly more efficacious than for women. However, it is much more expensive and (more important) has not been around long enough to see the adverse impacts that only emerge after decades of treatment of large populations.
Human Growth Hormone (HGH). The pituitary gland manufactures HGH for our bodies. Too much leads to gigantism in children or acromegaly in adults. Both of these conditions are diseases and lead to shortened life expectancy. However, some athletes believe they perform at higher levels if they take HGH and it is included in the banned performance enhancing drugs. Whether it actually enhances performance or not is another question altogether and I will not address it for now. Is it effective as a preventive drug to lengthen life and enhance life is the issue of concern in this particular string. See http://www.webmd.com/diet/features/the-truth-about-hgh-for-weight-loss and http://www.mayoclinic.com/health/growth-hormone/HA00030 for discussions of whether this drug helps in weight loss and prevention of aging. There is no evidence that this very expensive drug is effective for any treatment other than that of treating persons with documented deficiency of HGH (very rare conditions). Moreover, the so called oral HGH preparations are nostrums that are ineffective. On the good news side, most of them are also harmless.
So, in my analysis of cost and clinical effectiveness of prevention cares, I judge HRT and HGH treatments to be neither cost nor clinically effective when used for preventive care. Both have documented value for those clinical conditions in which a patient has documented illness due to deficiency of the specific hormone in question. HGH deficiency is very rare and should be treated by an experienced endocrinologist. Sex hormone deficiency (male or female) is less common, is a normal aspect of aging, and usually does not require treatment. If HRT is used, close monitoring for side effects is important. In men, HRT cannot be done with oral medicine, it requires either injections or a topical ointment.
“Again, I am NOT proposing an agenda. I wrote this piece in order to analyze some of the aspects of cost effectiveness and clinical effectiveness of preventive care.” (ETH)
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I am not, as you seem to suspect, deliberately misusing words. I am generally very precise in my use of words, HOWEVER, since it appears customary for us all to use “similar words” as interchangeables/synonyms, in the comments section here, I’ve taken to using “similar” words interchangeably as well, in this case I’ve taken to using “policy,” “analysis” and “agenda” interchangeably. . .“Same difference in Brooklyn,” as they used to say.
All I’m noting is that neither the Democrats NOR the Republicans are offering any such a policy in any possible alternative to the ACA.
I’m not tremendously familiar with many PEDs, although when I ran track in College I engaged in what’s been called “blood doping” (harvesting, concentrating your own blood and then re-introducing into the body prior to endurance competitions) and I used EPO, both of which boost the number of red blood cells in the body and make oxygen transport more efficient.
When I got on the FDNY I encountered many fitness fanatics, some of them serious body builders ALL of whom used a wide variety of PEDs in varying (often very large doses) dosages.
I never sought to bulk up, but instead sought to increase stamina and endurance. I rarely used weights, but did use chin-ups and pull-ups to strengthen and define the upper body.
For that reason (not wanting to bulk up) I was never interested in testosterone or other anabolics usage, BUT most of what I’ve read and everything I’ve seen seems to indicate that so-called “steroid use” poses little actual danger, given that I’ve seen guys who’ve greatly OVER-used various anabolics suffer no ill effects over 20 year periods. As one example, the links to brain cancer, as alleged in the “Lyle Alzado case” seem entirely spurious.
Given that, I doubt there’s much danger in a person (male or female) maintaining normal hormonal levels throughout their lives). A guru on the subject is Ellis Toussier (http://www.rajeun.net/essential.html). . .a very interesting guy. One Sloan-Kettering study that looked at juvenile cancer patients found that virtually all of them had BELOW average HGH levels for their ages and when their HGH levels were brought back to normal levels and maintained, most of them went into remission.
I HAVE used Sermorelin (a growth hormone releasing peptide once marketed under the name Geref, along with GHRP-6 (another growth hormone releasing peptide). I did that because I preferred to stimulate the production and release of my own natural HGH rather than inject a “bio-identical” synthetic. Once you begin injecting a synthetic the pituitary begins producing/releasing less of its own natural HGH and you have to inject the bio-identicals for the rest of your life to maintain levels.
BUT should my body one day cease responding well to the Sermorelin, I wouldn’t rule out the use of bio-identical HGH (like Norditropin). You are absolutely correct in noting that there is no oral or nasal HGH. Such products ARE shams. The only actual “bio-identicals” are injectibles, like Humotrope and Norditropin.
That said, I believe that Ray Kurzweil is right that we are on the verge of being able to genetically re-make the entire human body. That is, possibly, within 20 to 25 years we’ll be able to reset the body to an optimum age-level, genetically alter predispositions to cancers, etc.
That will almost certainly usher in the next major human shift, the period where the lines between the “haves” and “have nots” will be marked by the differences in “the enhanced” and the “non-enhanced.”
As fraught with potential risk and abuse as that is, that cat’s already out of that bag. Rogue commercial interests WILL NOT allow governments to shut down such an incredibly lucrative and high-demand service. Smaller government swill also NOT allow other nations to deny them access to the “next BIG thing.” It will find a home somewhere and some local economy will benefit spectacularly from the virtual Ford-IBM-GE-Apple-MS combined of the near future.
BUT back to the “policy-analysis-agenda” issue – preventive care even in the form of pre-screenings, etc. does little to reduce the ultimate costs of health care. Yes, such a policy WOULD almost certainly catch more cancers and other diseases earlier in people, but that would still inevitably lead to more expensive albeit more successful treatments and outcomes.
That’s the rub – we simply don’t have the money, nor can the money be generated to provide EVERY American with an “excellent” level of healthcare.
We CAN (probably) provide everyone with a “bare bones” (4 maybe 6 visits per year and maybe up to $10,000/year in healthcare expenditures with no “rollover”), but “excellent care” would require the purchase of available “gap insurance” at market prices.
America’s businesses and industries have been pushing for some form of “universal” or “single payer” plan for eons and they’re RIGHT to look to get out from under that ponderous burden.
In another post a fellow poster here derided market pricing as “rationing,” without noting that such rationing is “GOOD” rationing, as opposed to “BAD” government-rationing, where ultimately the politically connected get gold-plated treatment, while the less fortunate receive substandard care, like under the NHS.
As that other poster noted about healthcare, that SAME market also “rations” housing, food, clothing, etc. – as “high-income” (more productive) people get access to better quality housing, better, more nutritious food, better clothing, etc. In that way the market rewards productivity and punishes a lack of productivity via pricing.
There’s no reasonable economic argument against that market-based reality and of course, that poster, to his credit, didn’t attempt one.