Two recent New York Times articles jumped off the page at me. The first, on the recommendation by the U.S. Preventive Services Task Force to forego routine screening for prostate cancer with the PSA test, received wide media coverage. The second, on an Institute of Medicine (IOM) panel recommendation that costs should explicitly be considered in deciding what benefits must be provided by insurance plans, received less attention. Both deserve attention from population health advocates and policy makers.
The reason for the PSA recommendation is that the best scientific evidence reviewed by the panel over several years shows that such routine screening does not save lives overall and “often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many.” Health care groups and patient advocates were quick to criticize the panel’s findings, in a similar pushback to the recommendation two years ago against routine mammography for women in their 40s.
While most of the PSA test media coverage has focused on effective care, we should also consider the panel’s recommendation from a cost-containment imperative. The fact is, resources are becoming increasingly limited and both Republican and Democratic policymakers (not necessarily office holders) agree that Medicare spending must be reduced to reduce debt – and, some argue, protect national security in the global economy. Some facts to consider:
- As much as 25% of all health care expenditures are considered ineffective;
- Miami spends twice as many Medicare dollars per person as Minneapolis but gets no better results;
- We spend much more than any other nation on health care, with worse results.
There are two ways to achieve cost savings: provide fewer services and/or charge lower prices for each service. Any mention of this triggers loaded words from “rationing” to “government death panels.” I believe that while limiting services which have benefit is ethically and analytically challenging, eliminating those such as PSA screening with no benefit and even harm is not. But we must keep in mind that personal, professional, and political interests do not always align with the evidence: the New York Times article asserted that health reform legislation requires Medicare to pay for PSA screening regardless of the panel’s findings.
That the IOM committee should have to make a case for cost consideration in benefit design indicates how far from rationality we have strayed. I believe we can get back on track by agreeing that:
- Cost containment is a national security priority;
- We are wasting resources now;
- We should channel our resources toward cost-effective investments in prevention and the social determinants of health (the Obama administration is very short-sighted in proposing $3.5 billion in cuts to the already modest Prevention and Public Health Fund);
- We have opportunities to shift resources from ineffective health care to population health through community benefit reform and innovations from the Centers for Medicare and Medicaid Services (CMS).
We can’t have it both ways. We can’t lower costs without considering them. If evidence is not used to guide policy choices, what is the alternative? Perhaps we do need “shock therapy” to have evidence and economics drive our policy thinking. We can’t solve our health care and population health challenges without it.