I’m going to start right out by admitting that I am going to raise questions to which I do not have a coherent answer.
In the comments to Rose’s post about buying “green” products, Jason shared a link to this essay by Robin Hanson about healthcare costs. In it, Hanson argues that much of what is spent on healthcare does not actually yield greater health for the populations in question. He makes several arguments that I am not particularly well-qualified to address (I do not know if his points about data mining effects in interpreting certain data are sound, for example), and he makes further proposals that aren’t quite my cup of tea (he suggests making medicine less prestigious, which may indeed lower medical costs but would also [if I were to be fully honest] make me less likely to want to do it, especially if it were to go in hand with paying me less money). To my reading, he is rather more skeptical about the benefits of medical care than I think is justified, and doesn’t admit the possibility of as much ambiguity in the benefits of care as I think exists. However, I’ll admit that I was somewhat relieved to see that he seems to be relatively more forgiving of pediatric care, so perhaps I’d emerge from his policy recommendations comparatively unscathed.
That said, I am largely inclined to agree with much of what he writes. I, too, believe that much of the medical care that is administered in the United States is of questionable efficacy or benefit. I alluded to this in my piece for the Inequality Symposium, in which I suggested that much of the money spent on the patients in the top 5% of healthcare expenditure (who account for 50% of the total healthcare expenses in this country) might be saved if policy makers, physicians and patients could create a better approach to end-of-life care. Since I’ve already said that, however, there’s another question I’d like to raise today.
Hanson writes this:
King Solomon famously threatened to cut a disputed baby in half, to expose the fake mother who would permit such a thing. The debate over medicine today is like that baby, but with disputants who won’t fall for Solomon’s trick. The left says markets won’t ensure everyone gets enough of the precious medical baby. The right says governments produce a much inferior baby. I say: cut the baby in half, dollar-wise, and throw half away! Our “precious” medical baby is in fact a vast monster filling our great temple, whose feeding starves our people and future. Half a monster is plenty.
Do you have little voice in health policy or research? Then at least you can change your own medical behavior: if you would not pay for medicine out of your own pocket, then don’t bother to go when others offer to pay; the RAND experiment strongly suggests that on average such medicine is as likely to hurt as to help. [emphasis his]
As we draw our swords and figure out how we’re going to bisect this metaphorical infant, it’s worth asking who gets to decide which part we’ll keep. Hanson’s bolded statement above presupposes that the baby bits we’ll be throwing away are the ones foisted on a credulous public by an overly-influential and arrogant medical establishment. And I’m willing to concede that there’s something to that. But the converse is also true.
I’ll take a relatively anodyne example from my own practice. On a consistent basis, I will see patients with some constellation of vague symptoms — fatigue, malaise, miscellaneous aches, “not himself.” And quite often the parent will request that the patient be tested for Lyme disease, which is endemic in the area where I work. Now, these are patients who do not actually have symptoms of Lyme disease, and for whom my clinical suspicion is very low. In addition, the diagnosis of “chronic Lyme disease” to account for such symptoms is scientifically invalid, and those who make a practice of treating it are engaging in chicanery. (I await the commentary of the Lyme community.) I tend to be a therapeutic minimalist, and am loath to order tests or interventions that don’t have a clear clinical benefit. I particularly hate sending Lyme serologies under these circumstances, and do my best to dissuade the parents. But sometimes they insist, and sometimes I relent. (I have yet to uncover a plausible case of chronic Lyme disease under these circumstances.)
They insist the tests are a legitimate medical expense. I dissent. Who picks up the tab?
I have raised questions along these lines before. In general, I believe that (consenting adult) patients should have the right to irradiate themselves with unnecessary CT scans and exsanguinate themselves with needless blood tests. It’s their body, after all. But then who should be made to pay for them? I tried and failed (after being transferred from one person to another no less than a dozen times) to find out how much Lyme serologies cost using the lab we order through. The best estimate I could find via Google was about $200.
It’s all very well to say that patients should be made to pay for tests I don’t think are clinically indicated, in which case the power to facilitate payment by private or public insurance rests with me. But for many of my patients, $200 for a blood test would be prohibitive. Using Hanson’s formulation above, if they had the money they would pay for the medical care if they could, but they can’t and thus want someone else to do so. Given Hanson’s skepticism of medicine in America, would he endorse my role as a gatekeeper in this situation? Are doctors only to be trusted when they’re denying care, and not when they’re recommending it?
Of course, this discussion concerns something as relatively inexpensive and picayune as a blood test. What about a referral for a disease I feel competent to manage myself when parents want a second opinion? Or a third? What about the decision to withdraw care if the patient or family wants it, but physicians believe it to be futile? Yes, many patients get needless treatment at their medical providers’ recommendation. But many also get it by their own request. Who decides when it gets withdrawn and who pays for it when it is not? Does this not establish a system under which the affluent get all the care they want while the poor are made to accept the dictates of their medical providers? Is this proper?
I imagine that Hanson and I would agree on a lot. I do not have such a glowing opinion of my vaunted profession that I do not think it intervenes too much, presumes too much, costs too much. I’d happily sit down with him and whip out a red pen, slicing sword-like at much of what is needlessly ordered and prescribed. But what about those circumstances when I’m not the one who wants to spend the money?