Prostate-cancer study shows vexing problems of health-care reform
Kelly Brewington's story on the newest study on prostate-cancer tests illustrates some of the dilemmas surrounding health-care reform. The study she writes about points up the problems with the "preventing illness will save money" argument. It also demonstrates the problem with arguing that we're consigning people to "death panels" unless we spend as much as it takes to save every single last life, no matter how expensive it becomes. As Kelly reports:
Because many men are diagnosed with cancer that will not cause symptoms and will not kill them, the screening tests save few lives, the authors conclude.
To be more specific, some studies suggest to save one person's life from prostate cancer, the system has to test 1,000 men and treat about 50 of them through surgery, radiation or both. That's very expensive. Sure, we're saving a few lives. But we're also investing a ton of money that could be spent elsewhere in society, and getting relatively little in return.
Even the current protocols, which suggest men start getting tested for prostate-specific antigen after they turn 40, are controversial. It used to be 50. The study, Brewington writes, has "reignited a long-simmering debate in medical circles on the merits of the blood test." Why perform it, the argument goes, when it triggers so much unneeded treatment -- treatment that sometimes causes harm such as impotence or incontinence?
But if you're the one guy out of 1,000 whose life is saved (and somehow we can magically, retrospectively identify you), you're not buying that argument. "Don't sent me to the death panel!" you'll say. But why stop there? Men as young as 35 sometimes develop prostate cancer, and we don't routinely screen people their age. If we did it would add millions in costs to the system, make preventing a few prostate deaths even more expensive and inefficient and drive the cost of health insurance even higher.
So by decreeing age 40 as the cutoff for routine tests, we're rationing prostate-cancer detection now. Is that the right age? The job for society is to figure a way to deploy medical resources against prostate cancer and a thousand other diseases so that both the costs and the benefits are reasonable. But nobody, Democrat or Republican, wants to admit this.
Comments
I don't see how this is a dilemma. If a 40 year old wants a prostate exam let him pay for it. Same for the 50 year old. Someone must pay for each and every medical exam and treatment so why not have it be the person receiving that service?
Put another way, if you are not paying for your preventive health care, who is? And why that person and not yourself?
Should I expect my neighbor to pay for the gas I put in my car? Or to pay for my car insurance? What is so special about health care that allows one to assume the burden falls on the collective? We do not apply this philosophy to food, shelter or transportation. Then why health care?
Posted by: Dan | September 1, 2009 7:52 AM
I agree with "The job for society is to figure a way to deploy medical resources against prostate cancer and a thousand other diseases so that both the costs and the benefits are reasonable."
Posted by: NotableM | September 1, 2009 8:14 AM
Dan: Good thought. But suppose you get the test and learn you have metastasized prostate cancer. You need chemo, radiation and surgery. It's going to cost $200,000 -- not an unusual bill for cancer treatment. Would you have the patient pay for that personally? Could you afford it?
Posted by: Jay Hancock | September 1, 2009 9:39 AM
Jay,
To answer your question, the situation you present is precisely the reason for insurance.
Insurance should not exist to pay for tests. It should exist to pay for the 1 in a 1000 case where treatment is required.
The parallel is one doesn't purchase car insurance to pay for maintenance. One obtains car insurance to cover to protect against the rare but costly accident or lawsuit.
Posted by: Dan | September 1, 2009 10:14 AM
The discussion above overlooks the costs of treating metastic prostate cancer which insurance also covers. It also overlooks current day protocols which have advanced well beyond the procedures int he studies (which are hopelessly contaminated in any case). As far as who should pay, I would gladly pay on my own but then why should I or society have to pay for someone who refused the screening or couldn't afford it, and then had to be treated for the rest of his life as the cancer spread.
Posted by: Lee Smith | September 2, 2009 8:02 AM
Dan, people purchase car insurance because it is absolutely illegal to drive in any state without it. That's why people purchase car insurance, and even the level of coverage they must purchase is dictated legally in some states. Car insurance is helpful from my point of view (paid for my smashed-in windows when I lived in the city), but I know others who aren't amused by the legal requirement for it. Nice try, though.
Returning to the original topic, though, I don't understand the attitude of those who want fantastic care for themselves, but also don't want to have their neighbors have equivalent levels of care. It blows my mind. I'm on a good insurance plan, and many common and basic health care checkups are taken care of by my health insurance plan. I want quality access to health care for my friends and neighbors because I want good things for them, too. Why is this looked upon as a bad thing in current American society?
Posted by: Laura | September 2, 2009 11:24 AM
Laura,
You clearly do not understand car insurance and general issues of liability and financial responsibility.
You also do not understand the role economic incentives and the tragedy that occurs when incentives are distorted or eliminated.
That we could all live like kings and queens is a lofty desire. Since you apparently have given it some thought please share your plan. 5000 years of human civilization have failed to achieve this nirvana but since you believe it can happen why not give it another shot?
Posted by: Dan | September 2, 2009 4:04 PM
Testing for prostate cancer is standard of care in most communities. Meaning that if it's not performed, and the patient is later diagnosed with prostate cancer, the physician can be sued and the physician will lose. Even if the conversation about the risks and benefits of the PSA testing is documented in the chart. On the other hand, the side effects of being treated for prostate cancer are well known, and so even if there is a bad outcome, the physician is in the clear. It's not worth the time or the risks for physicians to explain the nuances of the PSA test to the patient.
Posted by: Prostate Problems | September 9, 2009 3:44 AM