Monday, November 9, 2009

The Disease Management Care Blog Learns A New Term: 'Decremental Cost Effectiveness'

Dennis Hopper, a Disease Management Care Blog fav thanks to his roles as a 60's addled motorcyclist in Easy Rider, a manipulative scheming huckster in Boiling Point and a sociopathic bomber in Speed, is battling prostate cancer.

The DMCB wishes him all the best and not just because Mr. Hopper was an inspiration for an early DMCB post.

And thanks to another Dennis Hopper quote:

Pop quiz, hotshot. There's a bomb on a bus. Once the bus goes 50 miles an hour, the bomb is armed. If it drops below 50, it blows up. What do you do? What do you do?

....the DMCB gets to think about 'decremental cost effectiveness.'

This is a concept raised in a November 3 Annals of Internal Medicine article by Aaron Nelson and colleagues titled 'Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation.' The authors reviewed over 2000 peer review articles on new innovative therapies that included cost and benefit in their analyses. While the majority of the innovations increased cost and benefit, there were nine articles that saved a significant amount of money in exchange for a small decrease in quality. Examples included doing percutaneous coronary interventions vs. more expensive and better open heart surgery, using watchful waiting for inguinal hernias instead of routinely operating on them and using drugs to treat reflux disease with symptomatic heartburn instead of laparascopic surgery. These treatments were almost as good, but were a heluva lot cheaper.

The point of the article is that the medical literature on medical innovation is characterized by a 'race to the top' and little attention is being paid to the economic trade-offs that routinely occur in other parts of our economy. Given our growing national interest in finding health care bargains, giving consumers the option of spending far less money is exchange for giving up a slightly greater benefit may not be so outlandish. This has implications for how comparative effectiveness research (CER) should be conducted in the short term, and what we'll need to do to bend the cost curve over the long term.

So pop quiz, hot shot. There's a health care cost inflation bomb on the body politic's bus. Once we find 2009 health reform doesn't work, that bomb is armed. If the cost curve doesn't drop, it blows up. What do you do? What do you do?

1 comment:

Devon Devine, JD said...

Thanks for the great term. I've been thinking about this in telemedicine. How do you overcome the inertia of a system that promises perfection? While encouraging, it would seem that validation of 9 decremental cost effective procedures is too microscopic a data point to change clinical practices. Given my background, I tend to think of medical malpractice reform as touching a broader set of behavioral levers. Then again, medical malpractice reform is a wicked hard problem so maybe you start with influencing the "standard of care" concept through the constellation of deliberative bodies that define it.

Telemedicine would include a whole group of evaluative techniques that fall short of in-person diagnosis but are so much cheaper. Especially cheaper than the long-term cost of forgoing care entirely due to the hassle of scheduling, waiting rooms, etc.