Monday, June 29, 2009

Cost vs. Benefit in the Healthcare Reform Debate: More on Pacemakers in Centenarians

In its Obama Pacemaker post, the Disease Management Care Blog pointed out that critics would use the President’s convoluted response about the merits of a $30,000 device in a 100-year-old against him. As if on cue, the Wall Street Journal (WSJ) editorial pages mined Mr. Obama’s answer and came up with an interpretation that predicts that government rationing is around the corner.

The WSJ’s clairvoyance aside, the DMCB has some Peggy Noonan- inspired (and unsolicited) advice for reform-minded policymakers who are struggling to answer questions about cost and value: we need to reduce our wonky paragraphs down to sentences. There is a time for careful reasoning and then there is a time for conviction. If meaningful reform is to occur, now is the time for the latter.

Take disease management, for example. While it can be thought of as ‘evidence-based population-based care management initiatives that seek to achieve maximum health care value for persons with chronic illness,’ another way to explain it is ‘your nurse that’s there to help you.’ The medical home is supposed to be a ‘team-based patient centered primary care system of care that offers comprehensive personalized care coordination,’ what it really is ‘your own family doctor on steroids.’

And what was the issue that the President was trying to communicate with the pacemaker question? That we are reaching the point where we can no longer support modest individual health gains at huge taxpayer expense. No wonder he dropped his usual laser-sharp eloquence.

Consider the following graph: as health care spending for any group or population or country increases (from low to high on the horizontal axis), the overall benefit as first increases sharply (‘A,’). Then – as more money is pumped in – the incremental additional benefit begins to slow down (‘B’), stop (‘C’) and then actually declines (‘D’).

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.

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