Friday, November 20, 2009

The good of the many

I am the last person on earth who should be commenting on anything even remotely political. I'm going to admit that 90% of politics bores me to tears, in part because it feels like everyone is talking in circles all the time. I imagine they aren't - but I can't readily tell the difference.

However, I do feel the need to comment on this whole healthcare thing. And, the suspicious release of multiple studies in the immediate wake of Obama's "no unnecessary procedures" declaration all of which seem to imply that breast exams and pap smears and prostate exams are probably not really that necessary every year or at all for many populations.

The beloved Ira Glass did a fine segment a while ago on This American Life on this problem, but somehow didn't say the one thing I can't help but thinking - and thus, will use this blog to rant about:

The Good of the Individual and The Good of the Society are not always well aligned. 

That's the core problem. In our society, too many  men are treated (apparently) for prostate cancer that is otherwise reasonably benign. Let's say (I have no real numbers) that 80% of men are fine, so the test was a "waste," 15% would be fine, but because they caught something in the test, it was treated unnecessarily, costing money and, due to the pain of treatment, causing spurious pain to those men. And finally, 5% truly really absolutely needed to catch the prostate cancer and were saved by this test.

The problem is that, for society, it makes sense to discontinue the test because of all the pain (15% of men) that are basically suffering because of it. Or, at a minimum, to discontinue treatment on people in that group (if they can be identified). But, to anyone sitting in the 5% bucket, that test was lifesaving. As a society, we've lost by testing. As an infected individual, they lose by not-testing.

For every treatment, there will be those that could have been saved - and many that might have been spared some pain. As a society, that has financial ramifications as well, which, of course, no one likes to consider in matters of life and death. 

In order to balance the heathcare books, we're being asked to take on more individual risk (or perceived risk) in exchange for a societal, global gain. But, no one will do that (hello, tragedy of the commons!) without some promised payout on the other end - like "if we all do this, when people do get sick, the hospital will be a ritz carlton). So, we're at an impasse.

Thoughts? Am I smoking something? And if so, should I be charged more for healthcare....?


Priya said...

I think you point out a flaw in the system. The system should be optimized on some key variable, such as life expectancy or avoidance of major illnesses. Not, cost. Most likely if the govt publicizes these screenings are not necessary, it will eventually become seen as an accepted sanctioned practice. It probably won't improve life expectancy or major illness avoidance stats, though.

There must be other ways to reduce the costs of the healthcare system. What about taking a tool from the playbook of every good McKinsey consultant and consolidate real estate and supplies? Have you noticed how many random doctor's offices there are in every corner of every office complex? Consolidate all those into a government owned building in every city, cut down on the waste.

I think the government has mis-optimized and could go deeper on the cost cutting

hornett said...

I agree, healthcare isn't a cost issue. It isn't a question if we can afford it, but it is a question about what kind of human society we want to be.
The real trick here is to get at the underlying problems. Why do tests give so many false positives? Why do doctor's interpret results in the way the do? Do they knowingly do unnecessary procedures? These are questions for Levitt and Dubner methinks.

Sheri said...

I couldn't agree more, here is an email that I sent out after I heard about the new task force recommendations:

Hi everyone-

I wanted you all to know that I am completely opposed to the new recommendations laid out by the US task force on breast cancer and the need for mammograms.

The previous medical trend had been to offer routine mammogram starting at the age of 40 to prevent the spread and aid in the detection of early breast cancer. Now, with Obama care, the new recommendation is for women to undergo a routine mammogram ten years later, now at the age of 50. This is the new recommendation that would cause hundreds of thousands of women to miss the golden opportunity of early detection and treatment. In addition, breast cancer is the #2 cancer to cause metastatic disease to spread to the brain, and we see hundreds of women a year who have this unfortunate diagnosis, carrying with it a life expectancy of 6-8 months.

Its important that you demand your mammogram at the age of 40, (or sooner if concerns) and not let the government allow the beginnings of their "health plan" to filter into the general population thereby causing mediocrity in our medical system to thrive. Of note, no oncologists sat on this task force....

Please pass this along as you see fit....