Bioethics Forum Essay
The Difficult Child of Medical Progress
The most seemingly sensible diagnosis of our health care cost problem over the years has been to reduce or eliminate waste and inefficiency. Of late that interest has greatly accelerated. Commanding particular attention were an article in the Journal of the American Medical Association by Donald Berwick, former administrator of Medicare and Medicaid, and Andrew Hackbarth and a set of recommendations on reducing unnecessary treatments by Choosing Wisely, an initiative organized by the American Board of Internal Medicine. A campaign of that kind allows an end run around rationing arguments and other politically unpopular blunt instruments to manage costs. Instead, better organization and management and reduction of unnecessary tests and useless treatment, fraud and abuse, and administrative complexities, are the targets.
Far less explored and more troubling have been two other features of American health care that no less deserve critical attention: its embrace of unlimited medical progress and technological innovation as a core value, and the economic costs of success in combating illness and death. They must be dealt with together to solve the waste and inefficiency problem, The latter have working against them a steady flow of (generally) more expensive technological innovations and treatments constantly fed into patient treatment. Much of what is now called waste is a child of progress: marginal health gains at higher costs.
The core values of medical progress and innovation–as with the exploration of outer space, an endless frontier–have been with us for many decades, nicely epitomized in the rapid rise and bipartisan support of the National Institute of Health. Nixon’s 1970s war against cancer was matched by hardly less zealous battles against all the other leading medical killers, notably heart disease, stroke, diabetes, and Alzheimer’s disease. And progress there has been: a significant increase in average life expectancy, a decline in disability, a steady lowering of mortality rates for most diseases, and many improved ways of dealing with pain and mental illness. There is much to be thankful for, and yet we have never confronted the social and economic cost of that undeniable success–and precisely as a success–as if too self-evidently valuable to be examined. The anodyne focus on reduction of waste and inefficiency seems to assume there is no problem with the underlying model of medicine that animates our health care system. That is a great mistake.
Medical research raises, not lowers, the costs of health care.As the Congressional Budget Office concluded in a 2008 study, “examples of new treatments for which long term savings have been clearly demonstrated are few . . . improvement in medical care that decrease mortality . . . paradoxically increase overall spending on health care because surviving patients use health services for more years.” Some years ago the NIH prudently stopped publishing an annual chart that showed the parallel rise of costs and research expenditures. That is not a message that the NIH cares to underline for Congress.
Cures and prevention have longitudinal costs.The cure of one disease or its prevention in a person’s life sets the stage for the death of that person by another disease. It is possible, and not uncommon, for a person to have his heart disease successfully treated at 65, a cancer cured or put in remission at 75, and then to incur Alzheimer’s at 85. It is the cost of health care over an individual’s life time, not individual instances of care, that is the key cost figure. We will usually not know what the successor disease after prevention or cure in our lives will be, but there will be one.
In one important sense of course it is a triumph that we can get patients through one crisis after another. But the 1 percent of patients who consume some 21 percent of health care costs, usually succumbing gradually from multi-organ failure, illustrate the progress problem. Fifty years ago they would have died faster and, in many cases, with less suffering. We have traded off shorter lives and faster deaths for just the opposite, longer lives and slower death. The cost of caring patients with for cancer and heart disease has increased even as the death rate for both has declined.
Technological innovations usually yield marginal benefits. There is surely useful medical progress and technological innovation. But despite the assorted wars against disease over the past 40 to 50 years, none of the major chronic diseases has been cured and the prevalence of death from infectious disease has remained much the same over that time. The main results of innovation been slow and small incremental improvements; great breakthroughs are in short supply.
The borderline between waste and marginal benefits, we should now know, is uncertain and often controversial. Mammography screening for women under 50 and prostate cancer screening for men over 75 are no longer recommended because they are generally useless, even hazardous, for most people in those groups. But some small number would undeniably die for lack of screening.
From an individual “better safe than sorry” perspective, both types of screening may be desirable. From a social perspective their marginality makes them wasteful. Yet since in general most marginal benefits represent instances of progress, they are likely to be adopted and used (even if argued about).
The fact that most innovation in recent years has produced marginal benefits only (drugs that save the lives of HIV patients are a notable exception), with none of the dramatic breakthroughs of the earlier era suggests nature is getting harder to conquer. The attractive dream of compressing morbidity–a long healthy life devoid of serious illness followed by a quick death–appears to have no good foundation (even though that happens with some lucky people). Most of us will die slowly of multi-organ failure.
A more direct confrontation with the fact that further progress is likely to be costly, thwarting progress against waste and inefficiency, is necessary. It is not just our expensive health care system that needs reform, but the progress-hungry model of medicine that animates it that must be changed. Progress can generate waste as well as benefits.
Daniel Callahan is President Emeritus of The Hastings Center and author most recently of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System (Princeton University Press). This fall, his memoir, In Search of The Good: A Life in Bioethics, will be published by The MIT Press and a collection of his essays, The Roots of Bioethics: Health, Progress, Technology, Death, will be published by Oxford University Press.
Posted by Susan Gilbert at 06/05/2012 03:31:07 PM |