Our Healthcare Needs
More Zen, Less Spend
Thursday, March 21, 2019
Breast Cancer Awareness Month (Photo credit: maf04)
This week’s New England Journal of Medicine (NEJM) has a couple of reports that got me to thinking about how much our healthcare system runs on the fuel of fear – not unlike how much of the Old Testament of the Bible used fear to keep the masses in line. Only in this case, fear is what’s driving our healthcare spending way out-of-line.
I’ve written before about the the problems this fear-based healthcare paradigm can create when it’s abused by opportunistic doctors and hospitals (see “America’s Health Scare System“).
The latest entries in the fear-monger follies include a report on the Swiss Medical Board’s multidisciplinary assessment of the effectiveness of screening mammography in preventing breast cancer deaths.
This analysis was unusual in that it was conducted not by just a medical oncologist (cancer specialist), but also a medical ethicist, health economist, pharmacologist, lawyer and a couple other non-physician disciplines.
This broadened perspective removes much of the self-interest in the usual physician-only reviews – especially those by the affected medical specialty with obvious conflicts of interest. The fact that these conflicts are now required to be disclosed doesn’t mean the conflicts no longer exist.
Indeed, studies show such disclosure has only emboldened greater deception in our medical research, as I discuss in Our Healthcare Sucks and here – proof positive of just how much it truly does suck. It’s a bit like Eddie Haskell getting caught in a lie and doubling down with even more outrageous lies (though Mrs. Cleaver was always nicely dressed).
Public Perceptions vs. Reality
Anyway, the Swiss report found that mammography – despite its legitimacy as a diagnostic tool – is grossly inadequate as a screening tool. Their review of the clinical evidence showed only one life possibly saved for every 1,000 women screened with mammography, while 70-100 women are subjected to unnecessary biopsies and others needlessly subjected to surgery, radiation therapy, chemotherapy, and all three combined.
Now 1 in a 1,000 isn’t enough to qualify as an effective screening technology – not even close. Yet public surveys cited in this report show that women think mammography screenings save 80 lives for every 1,000 women scanned. This grossly exaggerated view of mammography’s actual effectiveness is very likely wishful thinking driven in large part by an exaggerated fear of breast cancer’s actual toll.
These misperceptions are reflected in the following graphic from the NEJM study:
As Aaron Carroll nicely observes in his post about this at The Accidental Economist…
“If you think that breast cancer is going to kill 16% of all 50-year-old women in the next 10 years and that mammography makes a huge difference in the mortality rate, then you’re going to demand a universal screening program. Hell, I’d demand it if that were the case. Until we can change the perception of the public to more closely match reality, and make them realize that the harms may outweigh the benefits, we’re going to get nowhere in trying to make changes.”
They say in marketing that “perception is reality”. This hugely inflated public perception of screening mammography’s benefits is fueled by those marketers who cherry-pick the data to support their cause, while ignoring that which render it dubious.
This leaves us with a healthcare system – not just regarding mammography – in which perceptions, often ill-founded like those of mammography, dictate our healthcare priorities.
So while you may think your healthcare is determined by medical science, it’s really more about marketing. The medical science – the true balance of risk-and-reward – is often left buried in the footnotes, where they’re unlikely to affect public perceptions.
This obfuscation of the truth deprives the public of the knowledge needed to make intelligent and informed choices about their healthcare. The toxic ripple effects of this mainstream screening technique, for example, were enough for the authors to conclude the following:
“From an ethical perspective, a public health program that does not clearly produce more benefits than harms is hard to justify. Providing clear, unbiased information, promoting appropriate care, and preventing overdiagnosis and overtreatment would be a better choice.”
Yes, it would. But women’s legitimate fears have been so stoked by industry-sponsored “pink ribbon” campaigns that many are desperate to avoid death by breast cancer, however remote the actual risk.
This has led to our current phenomenon in which one study I cite in the book found many women with early stage ductal carcinoma in situ (DCIS) – which many dispute as being cancer at all – opting for the most radical surgical choice (it’s called “double radical mastectomy” for a reason) even more often than their surgeons recommended.
I and others have written elsewhere about the ethical crisis of overly-aggressive treatments promulgated by physicians who benefit financially from such over-treatment – a linchpin in our medical dysfunction. So when patients are even more aggressive than the doctors who get paid handsomely to perform these surgeries, it kind of suggests that something’s amiss.
In this case, it’s overblown fear fostered by medical greed (see “Got Cancer? Too Bad“) and a lazy and complicit media.
More Cancer Fears Exploited
Which leads to the second NEJM report this week on the astronomical cost of “next generation” chemotherapy treatments that now run to six figures a year for the drug alone.
This report focuses mainly on the lack of head-to-head studies to determine whether these pricey potions are any better than the less pricey treatments they seek to displace. The studies that have been done show little benefit in survival times despite their huge incremental costs.
Of course, a few additional weeks or months – in some cases, only days – may not seem worth tens of thousands of dollars in added healthcare costs to the rest of us, but the affected patients and their families are likely to disagree.
Still, our unwillingness to grapple with the moral question of just how much another day or week of life is actually worth – and how much we’re willing to subsidize it in our taxes and insurance premiums – is one reason why this issue goes unresolved.
The conclusion of the NEJM report?
“The high price of cancer drugs is unsustainable; and the need for less costly alternatives is greater in cases where the benefit of new therapies is marginal…(yet) high prices protect a drug’s market share, precluding challenges from cheaper alternatives (emphasis added).”
What they’re telling us is that the biotech industry is exploiting the public’s exaggerated fears of an early death – or of any death, really, however timely it may seem to others.
We see this in the public backlash to such reports as another step toward healthcare “rationing” – as if that were somehow unreasonable, even un-American (see “Obamacare: In Defense of Rationing” for my take on this).
Just Because We Can
Doesn’t Mean We Should
We really need to grow up as a culture, yet somehow future senior generations weaned on “selfies” and self-entitlement would seem to augur for more of the same – and then some.
So unless we change this from a fear-driven paradigm to something else, we’re facing a future in which healthcare costs crowd out every other aspect of our lives. Travel, entertainment, education, basic food and lodging will all give way to subsidizing this behemoth medical arms race in a futile attempt to squeeze another breath out of increasingly barren lives.
I propose we abandon this Old Testament fear-driven paradigm and turn instead to more of a New Testament, love-based healthcare model in which comfort and compassion replace greed and a search for eternal life on earth. What’s lacking in our healthcare more than high-tech advancement is low-tech, high-touch healthcare that’s actually about caring.
Besides, eternal life – if it exists – isn’t to be found in this life, and we’d be well-served to stop this desperate search for it. That’s a matter for religion, not medical science.
This doesn’t mean we should give up on further medical advancements, but rather that we adjust our perspective to find a better balance of what’s realistic – meaning affordable without pre-empting the other necessities of living – and what’s a futile and selfish search for immortality. We need, in short, to accept our inevitable ends as human beings.
Just because medical science is approaching the point where it may be possible to extend life beyond prior limits doesn’t mean we should devote the bulk of our economy to doing so – not if it means effectively bankrupting younger generations and consigning them to a bleak future of economic servitude.
If that’s what awaits us, our history will be written as one of selfishness and irresponsibility, not noble scientific or humanistic advancement.
No one wants to die, but no one’s living forever either. We need to find a better way to navigate our way than this obsession with more and more healthcare.
Maybe it’s not a New Testament mindset we need, but more of a zen thing in which we find a better, and healthier, perspective.
Whatever form it takes, we’d better start to do some soul-searching about our healthcare before the opportunists push us over the real fiscal cliff that awaits us.
What do YOU think? Why not weigh in with your own thoughtful comment below?