Dr. Bernstein on Germany’s proposal:
Patients with chronic illness currently pay up to a 1% maximum of their gross income for their health care, whereas the cancer patients who did not screen would have to pay up to a 2% maximum . . . But the ethical issue is whether patients who are suffering the emotional and physical pains of cancer should have another burden, a penalty of not having been screened for their disease.
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The validity of this approach depends on the value of screening. Screened patients will appear to live longer in most epidemiologic studies because the clock starts sooner; but do they in fact outlive their unscreened peers? Charging more to the unscreened presupposes that they cost more to the system. But if they do die sooner, do they perhaps cost less, as first there was the cost savings from not screening, then they died. The patients who do participate in screening, if they do live longer, might in fact cost the system more.
The financial incentive to screen has not been shown rational on two accounts.
In addition to the two accounts gasman mentioned, another one is the cost of screening itself. While the tests that can prevent cancer may cost money with the respect of treating the desease itself, the cost-saving potential of tests that detect cancer early but don’t prevent it is far from clear. These tests often result in overdiagnosis and greatly increase the number of people diagnosed with cancer. So you save on treating some people less aggressively, but you spend on treating more people. And then, those people whose life is prolonged may have a relapse later in life and have to be treated again. Or get diabetes or Alzheimer later in life and die sooner.
I believe the German plan is fundamentally unethical because it interferes with basic premise of informed consent/refusal. People should make medical decisions based on benefits and risks and how they apply to them personally, and these decisions should be between them and their doctors.
Tests are not risk-free. If today a government decides that they can penalize people for not screening, tomorrow a government or an insurance company can decide they can penalize patients for not getting treatment or not taking preventive drugs. If today a penalty German government proposes seems small, it can be greater tomorrow. Maybe one of our insurance companies takes their plan as an example and decides to refuse treating a 60-year old for heart desease because he/she hadn’t taken statins when he was 40. Oh, and every government is very competent in evaluating scientific evidence – have you noticed that one of the screening tests included in German plan is digital examination of the prostate?
I am scared of German plan: what is to prevent our own insurance companies or our employers to follow suit and to make penalties harsher? Any lawyers here? If a corporation makes screening a mandatory requirement for getting insurance, would they be within their rights?
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