THE TREATMENT DECEMBER 1, 2009
Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.
Today’s debate over the Mikulski Amendment will not quell the misguided debate over mammography occasioned by the U.S. Preventive Services Task Force (USPSTF) recent recommendations. There is just too much incentive to pile on. The Wall Street Journal editorial page mocks USPSTF’s skepticism as an example of liberal snobbery: “Rationing, what rationing?” (I will provide a $5 reward for the reader who submits the most plausible photographic negative WSJ editorial arguing the opposite view.) Senator Mike Enzi thunders: “Congress should not pass a healthcare reform bill that denies you the right to receive the medical procedure or treatment that you and your doctor agree is right for you,” And so on.
The issue is just complex enough to require two paragraphs of explanation to see why the above arguments are wrong. Despite some excellent coverage, few journalists have followed Merrill Goozner’s lead in actually reading and analyzing the Task Force’s report.
Still, I would not wage the battle for comparative effectiveness on this particular culturally freighted terrain, in part because I understand just how complicated these issues really are.
I once reviewed an Institute of Medicine report, which noted that the American blood supply system employs elaborate and costly HIV screening technologies to prevent a handful of blood-borne infections that would otherwise slip through. These policies are not even close to cost-effective when judged by standard criteria. Yet I believed then, and I believe now, that our nation is right to spend the money. Given the tragic history in which bad luck and bad policy combined to cause many needless AIDS deaths from tainted blood, this is not the arena for aggressive application of medical cost-effectiveness tools. Sometimes, the decision analyst needs to know when to click “file close” on the EXCEL spreadsheet.
Untargeted mammography for women in their forties strikes me as an inefficient, but not-so-terrible practice that will save a small number of lives and may reassure many women. The USPSTF reports that 1900 women age 39-49 must be screened to save one life. This is costly. It also results in many false positives which the American health system does not address very well. Mammography causes much anxiety. More important it leads to painful biopsies, avoidable radiation exposures, and needless surgeries that produce real health harms. Still, more harmful and costly practices provide better targets for similar scrutiny.
To be clear, we need to convince Americans that evidence really does, or should, matter. That's why it was encouraging to see a new statement on that subject from the American College of Physicians.
ACP, which represents 129,000 physicians, is one of America’s most respected medical organizations. The statement, released by ACP president Joseph Stubbs, notes that USPSTF recommendations
have regrettably been used by some critics of the health reform bills being considered by Congress to make baseless charges that the bills would lead to rationing of care.
The statement also points out (correctly) that the USPSTF “does not consider economic costs in making recommendations. “ It then goes on to say:
Under the bills being considered by Congress, the USPSTF will have an important role in making evidence-based recommendations on preventive services that insurers will be required to cover, but the bills do not give the Task Force--or the federal government itself--any authority to put limitations on coverage, ration care, or require that insurers deny coverage…Accordingly, patients will benefit by having a floor--not a limit--on essential preventive services that would be covered by all health insurers, usually with no out-of-pocket cost to them. Patients will also benefit from having independent research on the comparative effectiveness of different treatments, as proposed in the bills before Congress. The bills specifically prohibit use of comparative effectiveness research to limit coverage or deny care based on cost.
In its own wonky way, within an often-disheartening health policy debate, that’s Change We Can Believe In.