Leonhard on Prostate Cancer
David Leonhardt has a brilliant article on prostate cancer treatment. But of course it’s not really an article about cancer treatment at all, rather it’s an article about the need for payment reform in the health care system. To make a long story short, if early-stage prostate cancer is discovered there are a variety of possible treatment modalities and they cost different amounts. In principle, there could be a tough choice between a cheap and somewhat effective treatment and an alternative treatment that’s much more expensive and only a bit more effective. But in practice, we don’t even face that choice. It’s not actually clear how effective the different options are. And nobody’s really researching the issue. And even if they did, health care providers just get paid for delivering health care services not for delivering effective treatment.
So the incentive at the moment is for the whole system to push everyone with good insurance toward the highest-cost option and everyone without it to the lowest-cost option, all flying totally blind as to what works and for whom and why. It’s a great piece. I disagree a bit, however, with the tenor of Leonhardt’s conclusion. After quoting Senator Ron Wyden (D-OR) to the effect that the current legislation doesn’t go as far as one would like in changing this dynamic, Leonhardt concludes:
The current health care system is hard-wired to be bloated and inefficient. Doesn’t that seem like a problem that a once-in-a-generation effort to reform health care should address?
For one thing, it’s just wrong to imply that the bills currently in congress don’t address this issue. Leonhardt says as much earlier. They just don’t address it as fully or as robustly as one would do in an ideal world. But forward progress is forward progress. More important, I don’t think we should see this as a “once-in-a-generation effort.” The idea that there need to be big gaps between health reform pushes comes from the history of failed reform pushes. The 1994 health care blowup made politicians afraid of dealing with the issue. A successful bill would have the reverse effect. And even in the case of failure, the 15 year gap between 1994 and 2009 isn’t exactly a generation. And it’s worth noting that we had a major Medicare bill as recently as 2003. And of course there’s the long-run budget outlook:
That’s not sustainable, so whether or not politicians want to they’re going to need to keep addressing issues related to systemic health care cost growth.
Additionally it’s worth noting that part of the issue here is that without a track record of legislative initiatives in this area, it’s difficult for members of congress to write legislation that results in budget savings that the CBO will score. And hard as it is to take a tough vote to save money, it’s really hard to take a tough vote to save money that you don’t even get credit for. The only way around this is to start taking some modest steps and hope that modest steps produce modest gains that establish a track record and lay the basis for further efforts.
15 Responses to “Leonhard on Prostate Cancer”
Register
RSSLogin
Topic Cloud
ArchivesBlog RollAbout Matt YglesiasContact Me
Donate
July 8th, 2009 at 11:36 am
“But forward progress is forward progress. More important, I don’t think we should see this as a “once-in-a-generation effort.” The idea that there need to be big gaps between health reform pushes comes from the history of failed reform pushes.”
Meh.
We do have a “once-in-a-generation” to put a good legislative framework in place for future healthcare reform.
One of the reasons folks with more sense about the issue than Matthew think a robust public plan is important is that it will provide the groundwork for future improvement to the system.
If we pass a good bill this year, one that both works well and is popular with the public, future efforts at fine-tuning the thing will be politically easier. In a democracy, sustained programs really need to have broad electoral support.
If we pass a bad bill this year, one without a robust public option and/or one without decent subsidies for the median earner, future efforts at fine-tuning the thing will be next to impossible.
This year’s bill really will be the watershed.
July 8th, 2009 at 11:43 am
MY “health care providers just get paid for delivering health care services not for delivering effective treatment.”
Aye, there’s the rub.
July 8th, 2009 at 11:43 am
“And even if they did, health care providers just get paid for delivering health care services not for delivering effective treatment.”
I agree that paying doctors differently is a good idea. I vote for salaries with possible bonuses, just like any other professional.
However, I think you, and many people, oversell the idea of these pay-for-performance type measures. The biggest problem is that most of the variation in outcomes is due to factors beyond any single physician’s control. So paying based on outcomes would be somewhat arbitrary. It would be great if we could figure it out, but I think we’re a long ways off from that point.
July 8th, 2009 at 12:06 pm
Matt, your post is not quite right. The treatment option elected is more often a function of the personality of the patient than real knowledge about the alternatives. My client, a radiologist, was diagnosed with early stage prostate cancer. Well aware of the alternatives and the risks associated with each, he elected the most aggressive treatment. Why, because it’s in his makeup to take the most proactive course, even if a lesser but as effective alternative with fewer adverse side effects were available.
July 8th, 2009 at 12:10 pm
If we pass a good bill this year, one that both works well and is popular with the public, future efforts at fine-tuning the thing will be politically easier. In a democracy, sustained programs really need to have broad electoral support.
i was going to comment on this, but instead i’ll just bold it:
If we pass a good bill this year, one that both works well and is popular with the public, future efforts at fine-tuning the thing will be politically easier. In a democracy, sustained programs really need to have broad electoral support.
i want good health care reform, but i also want health care reform that sticks around through all the future gop attacks. this is only possible with a broad public buy-in. that’s only achieved when the public has some skin in the game. and that’s only offered with a public plan.
July 8th, 2009 at 12:11 pm
The biggest problem is that most of the variation in outcomes is due to factors beyond any single physician’s control.
That’s true. Looking at the “quality and outcomes framework” that’s part of the GP contract in the UK, though, a lot of the basic stuff is simply about good data collection and best practices: how many people have been diagnosed with X, Y & Z? How many of them have had a review in the last N months? How many of them have been symptom-free in the last M months? Have smokers been given cessation assistance? Have heart disease sufferers received cholestorol/BP testing and treatment? Etc. And that data gets factored back into the research.
I’m sure that that all sounds like Doctoring 101 to you, and it can possibly encourage a “teaching to the test” mentality, but as Atul Gawande has noted, checklists can make a difference.
July 8th, 2009 at 12:13 pm
So this is basically a disproof of your thesis that healthcare is not a good that people will consume as much of as is available, isn’t it? You can argue that the mechanisms at work here are doctor/research related, but at some point you have to make a comparison between methods that cost a few thousand dollars versus a hundred thousand dollars where the difference in outcome may be minimal. If I’m a patient and the difference is small, but noticeable and I’m shielded from the cost, of course I’m going to spend the money. And that’s one problem with the system. We need to have an open debate about whether that’s acceptable, not pretend that kind of problem can’t possibly exist. You can’t just rely on conducting studies to solve all these problems for you.
July 8th, 2009 at 12:29 pm
“And hard as it is to take a tough vote to save money, it’s really hard to take a tough vote to save money that you don’t even get credit for. The only way around this is to start taking some modest steps and hope that modest steps produce modest gains that establish a track record and lay the basis for further efforts.”
This is essentially backwards.
If the final bill keeps the CBO pricetag down, then subsidies for folks around the median level of earnings will be lower, the plan will be less popular, and it will be more difficult to politically achieve future reform.
Conversely, if the CBO pricetag is higher, then subsidies will be more adequate for folks around the median, the plan will be more enduringly popular, and future reform will be easier.
July 8th, 2009 at 12:38 pm
The ambulance came to the nursing home last night to pick up my father-in-law and take him to the emergency room…so he could poop. Second time it’s happened. The “assisted living” place refuses to do anything but call the ambulance. FUBAR>
July 8th, 2009 at 12:41 pm
1. We don’t know much about prostate cancer treatment effectivenes in large part because it’s a disease that affects men.
2. Leonhardt’s article failed to mention erectile dysfunction and incontinence as treatment side effects. That’s just baffling.
3. Leonhardt says that we’re paying billions more than is medically justified. But he’s just switching the burden of proof, not making an argument, and he seems to entirely ignore the question of side effects (see no. 2).
4. Yes, some men choose a less invasive option when given choices. In fact, many do. The new treatment options are less invasive! They’re more expensive too.
5. It is Leonhardt and Yglesias who think that this decision–weighing the evidence on effectiveness and weighing the non-monetary costs of the side effects–needs to be made by the US government. It doesn’t. We don’t all have to weigh uncertainty about effectiveness and the risks of side effects in the same way.
July 8th, 2009 at 1:46 pm
Why are the insurance companies willing to pay for the high-cost treatments that aren’t proven to work?
In theory, this would be the time for insurance companies, as private profit-maximizing entities, to hold down their costs.
It doesn’t make sense.
July 8th, 2009 at 3:28 pm
Leonhardt also fails to mention the explosion of doubtful diagnoses of early stage slow growing prostate cancers in the U.S. that were discovered using new tests with sketchy properties (specifically, far too many false positives). The jump in diagnoses in the U.S. compared to all other high income countries has been documented in medical journals.
Population based death rates from prostate cancer stayed quite stable across countries during this time, which suggests many of the diagnoses in the U.S. were not for dangerous cases of aggressive prostate cancer.
To some extent this higher diagnoses rate has come down, as knowledge of the testing problem spread among the medical community; however, the problem of what should be standard of care now that these tests are available is not completely resolved.
I disagree with the comment above that this shows people will just consume more care no matter what. It is also a problem of the U.S. medical-industrial complex that produces new technology designed as much to create revenue (through administering doubtful tests) as improve population and individual health.
This whole aspect of the problem is not discussed in the article.
July 8th, 2009 at 8:52 pm
You’ve misread the intent of the last sentence. The author did not intend to imply that these challenge should be met once a generation – rather he referencing the popular moniker in the media for the magnitude of the challenge to overhaul health-care as being appropriate.
July 8th, 2009 at 11:34 pm
Medicine is an observational science
It’s in a stage still where it works mostly by induction from observations, not deduction from general principles. It isn’t much like physics, which is unfortunately most people’s working model for how science is supposed to work. We don’t proceed from some grand unified theory of how prostate cancer works, which tells us what treatment to use for what stage of cancer. In the absence of grand unified theories, we have no choice but to work in the opposite direction, from observing the progress of individual cases as different treatments are tried. Throw something new into the mix, like the PSA testing wich only comparatively recently came into general use, and very often the result is that we have to start over again from scratch, as in this case where prostate cancer as discovered by PSA, undoubtedly because of selection bias, behaves like a different animal from prostate cancer that presents as symptoms or a rectal mass.
It is not even remotely scandalous that medicine hasn’t yet figured out a good working staging/grading system, with correlated best treatment for each such stage, for prostate cancer that incorporates what we have had to observe all over again from scratch about prostate cancer. Yes, in the absence of certainty that these early, PSA-discovered, prostate cancers really are categorically less aggressive than prostate cancer as discovered by symptoms or palpable mass, there is a tendency to assume the worst and go with treatments that will probably eventually be proven to be overly aggressive. But you don’t have to invoke evil doctors out for profit to explain that tendency to aggressive treatment in a situation in which a potential killer like prostate cancer has been found early, and it isn’t clear that foregoing aggressive treatment now will not lose the patient his only shot at survival. Treating docs don’t decide which issues get studied anyway, so it’s not as if the people who do make those decisions would profit from some conspiracy to not study early prostate cancer and its most effective treatments.
But what I found most offensive about this article of Leonhardt’s is the perverse prioritization of monetary costs over human costs. He thinks that there is systematicly unnecessary overly aggressive treatment of prostate cancer, and his concern is that this costs too much money. I think that the appropriate concern that overtreatment should raise first and foremost is that patients are being harmed, that unnecessary human costs are being incurred, and let’s worry about the monetary costs only after the much bigger problem of the human toll is corrected. In fact, since “invasive equals expensive”, stopping unnecessarily invasive treatment will, in most cases, also stop unnecessarily expensive treatment.
This inversion of priorities makes the author miss a key difference among the treatments he mentions. Removal or obliteration of the prostate, if that is necessary to treat prostate cancer, is a fairly massively invasive matter, because the body’s plumbing and wiring for all sorts of critical functions passes through or right next to the prostate, and its removal tends to involve the impairment of a lot of functionality. The fancier modalities cited tend to to be used because they hold out some promise of doing a better job than scalpel surgery of zapping the cancer without leaving the patient incontinent of bowel and bladder. Count the lifetime costs of these impairments into the equation, and a modality that avoids them, even if it costs much more up front, is still cheaper, in both human and monetary costs.
July 9th, 2009 at 9:00 am
Insurance companies make money by providing insurance more economically and efficiently than other insurance companies. As long as their competitors are covering the same sub-optimal procedure, they don’t need to eliminate it. In fact, if they do the work to demonstrate that the procedure is unnecessary, and fight the lawsuits to enforce their position, other companies will free-ride on their work, and ban the procedure at no cost. They lose money by eliminating a previously accepted but ineffective treatment.