TNR: fewer cures, more free lunches

Hunter-Gatherer points to an article in The New Republic by Daniel Callahan that advises an extensive multi-year study of the US health system in order to make a complete overhaul. In principal, I agree with Hunter-Gatherer's intuition that large comprehensive studies tend to be bad ways to conduct medicine and medical policy. However, there are other problems with the article, too.

(1) High health care costs are not necessarily a problem of old age. This is true in two ways.

First, in a general sense, chronic diseases of aging are probably less a problem of aging than a problem of accumulated modern life. The prevalence and cost of cardiac and cardiovascular diseases, and probably cancer as well, would be reduced by healthier lifestyles without withdrawing medical care. When I say prevalence and cost, I mean that not only would there be less of, for example, coronary artery disease, but recovery from procedures would be faster and management of the disease more efficient.

Second, in a specific sense, people in the 80yo+ category are generally our healthier citizens. When I worked on a PCU, it was easy to note fat patients and elderly patients, but no fat elderly patients were there recovering from cardiac catheterizations. To quantify this point, take kidney dialysis--an expensive medical cost that Callahan points out is predicted to increase by 150% soon. As the prevalence numbers from the US Renal Data System (here) indicate, diabetes and hypertension--essentially lifestyle diseases of modernity--alone count for about 3/5 to 2/3 of cases of End Stage Renal Disease, and the numbers for age of patient really kick in during the 50s and start dropping off for elderly people. What this tells us is that your average dialysis patient is not an oldster trying to hang on to a few more weeks of paltry life, but a middle-aged person who has been basically inactive, eats poorly, probably smokes.

(2) Non-coercive public health is maxed out. Callahan wants us to cut costs by spending more on "public health" and "primary care." But the numbers are in and public health is ineffective. Yes, it does a good job with cholera, but with chronic diseases, no. More public school breakfast programs and education campaigns are not going to cure problems caused by Captain Crunch and the couch. Public health officials know this, which is why they are eager to resort to coercive and semi-coercive methods. So, note: shifting attention to public health means giving un-elected officials the power to levy partially invisible and non-transparent taxes, fines, etc.

(3) You can't start preventing things in old age. Callahan wants us to increase preventive care for the elderly rather than spending a lot of money extending their last months of life after they get sick. Other than ensuring people get pneumonia and flu vaccines and get some excercise and nutritious food, what preventive care are you going to perform in the elderly? Does he have a magic bullet to prevent GI bleeding (one of the main reasons elderly people are admitted to our ICU)? No, I don't think so.

(4) Primary care is over-rated. Everyone wishes your dermatologist was a general practitioner, as if there were a connection between your zits and your higher insurance bill due to your neighbor's colon cancer that could have been solved more cheaply by more primary care office visits. This flies in the face of the "costly last few months of life" analysis of our health care system. While treating a cancer earlier might be more cost effective, it will be there whether it is caught early or late. If you are determined, as Callahan is, that cures for the elderly should be phased out, the cost-effectiveness of early treatment is a nullity. See this July's JAMA for a study showing that areas with more primary care physicians have higher costs for a very, very small reduction in mortality.

(5) Health care is over-rated. Callahan wants to see a series of neighborhood clinics with GPs, paramedics, and nurses instead of having people go to the hospital. This is stupid because the high cost of going to the ER is not due to intrinsic costs to the hospital. Take an EKG for your chest pain: your ER bill might be over $500 for an EKG, which involves hooking up a computer with electrodes. The disposable parts are 12 small stickers and a couple pieces of paper. The EKG is generally administered by unlicensed personnel making close to minimum wage and takes about 10 minutes. The paper is examined by a nurse for about 15-30 seconds, and then, only if something is amiss, by a doctor for another 15-30 seconds. The cost is not due to amortization of the EKG computer (~$15,000... in a busy ER, the computer might get used 30 times every few days). It is from the way the hospital spreads around billing in order to make an overall profit when it loses money on other procedures. In short, it is an accounting problem, not a you-used-expensive-ER-resources problem. If you go to an urgi-care clinic rather than an ER for chest pain, it isn't going to solve the problem of expensive ER resources, but if you're having a heart attack, it will mean getting examined by the ER again after your urgi-care clinic uses their paramedics to transport you there and lose you precious minutes in "door-to-table" time, a measure of how fast your heart attack gets solved.

(6) Research has large potential pay-offs. When a person develops Alzheimers we lose not only the cost of caring for them, but the economic benefit they bring to the community, which might range from still being able to work at white-collar jobs to letting younger people work by baby-sitting. Finding a one-off cure for Alzheimers would be a huge financial payoff, not to mention that the emotional eleviation would probably be worth even a large cost without financial benefit. The principle of vaccination was discovered in the 1790s, but the polio vaccine wasn't discovered until the 1950s. Alzheimers Disease wasn't even defined until 1910, and its cause was still a mystery. Giving up significant amounts of research into diseases like Alzheimers because we haven't found a cure in the last couple decades seems to me very ignorant, like a school-child saying they can never complete their homework because its too hard, and very stupid, like choosing to spend rather than invest.

Here are some alternative suggestions for health care savings:

(A) Throw out the idea of equality in treatment. Callahan wants us to start recognizing inequality between elderly and young, but he hasn't given up the idea equality altogether. Let's go several steps further. Let's figure out what the cost of certain behaviors and characteristics is so we can give patients a "health cost burden score." Are you obese and a smoker when you know perfectly well that you have a family history of heart disease and early cardiac death? Maybe your insurance company should deny you a heart catheterization. Do you come from a family of people who regularly live into their 90s? Maybe you should be treated for a condition in your 80s that a person from a family of people who live into their 70s should not be treated for in his 80s?

(B) Expanded use of mid-level providers. Without going into it too much, I'm pretty sure medical training is overkill for what many doctors do most of the time with most patients. Much of care is now algorithmic and much can be learned by PAs and NPs (or even RNs)--even minor surgeries. Mid-level providers get paid less and can be graduated faster than MDs.

(C) Increase research funding and allow researchers and companies more leeway legally and ethically to pursue cures and bring them to market.

(D) Allow people more access and control over their own care: if I can get my own BP cuff and order my own labs, I don't need to pay a doctor's office to be a middle-man for those things.

(E) Let food prices rise. For most of human history, people have expended most of their resources on obtaining food. Why should things be so different for us? Maybe if the cost of food rose significantly, more people would start "victory gardens" and decrease their consumption.

I don't pretend this is a comprehensive plan, but these are some alternatives to Callahan's plan. It strikes me that Callahan is quite old now. His message is essentially, "well, my generation tried to live forever and failed, so everybody should stop trying now and shift money into social welfare programs to take care of us." Guess what, Mr. Callahan--I have a good thirty or more years left before I have to start worrying about Alzheimers seriously, and I'll be damned if I'm going to let you defund my chances of staving off that horror. Up yours!