All those darlings of the health care economists – the Mayos, the Kaisers – apparently inhabit the A and B parts of the curve, while McAllen Texas has been accused of being on the C part of the curve. Open ended health insurers that pay for everything and anything are responsible for the ‘D’ part of the curve. That’s where infections happen among hospitalized patients, where mammograms in low risk women cause more biopsies than save lives, where unnecessary colonoscopies cause more bowel perforations than detect cancer and the where invasive placement of cardiac stents cause more damage than just taking pills.
The D part of the curve accounts for Medicare’s interest in stopping payment for services such as readmissions to the hospital for avoidable complications. Easy.
The DMCB thinks one attraction of comparative effectiveness research is that it can address the C part of the curve – if it is allowed to assess cost. Less easy.
The top part of the B curve is far trickier because that is where pacemakers in centenarians comes in. Very hard. There is cost (in this case, $30,000) that results in real incremental benefit (5 years of quality life and a daughter that can visit her in the home), but it’s not as much as the same pacemaker in a 60 year old (who would get 40 years of benefit, including years of taxable income and trips with grandkids to Disney World). The DMCB thinks the 100 year old got a worthwhile use of healthcare dollars. However, there are more difficult examples of higher cost with lower levels of benefit: one example includes cancer treatments that cost 6 figures and lead to an increased life-expectancy that is measure in months. Another may include the notion that everyone should have a regular physical examination, which rarely detects a problem.
Five other points while we grapple with this:
a) many policy makers think solving the C and D parts of the curve are enough to solve the health care budget crisis. The DMCB isn’t too sure about that.
b) don’t believe that money saved on the B, C and D parts of the curve necessarily means more money will be available for A. The money isn't necessarily wired that way.
c) don’t expect an individual physicians dealing with individual patients to solve this curve on a day to day basis no matter how you pay or decision support them.
d) the DMCB believes disease management and the patient centered medical home - which typically charge less than $100 per patient per month - occupy the steeper part of the B curve: the investment results in considerable increases in benefit.
e) while Mr. Obama ducked the pacemaker question with a paragraph, the day of reckoning is coming: sooner or later, we'll need to use sentences to decide what life-prolonging therapies we can afford and how we intend to afford them.