The United States takes the spoiled rich kid approach to health care

Currently, the United States spends approximately 3 trillion dollars on health care, which is roughly 18% of our gross domestic product (GDP).  Not only is this more than every other country in the world, but it’s also more than the next 10 largest spenders combined.  Looking backwards, health care spending rose steadily from about 9% of our GDP in 1980 to about 16% in 2008.  Looking ahead, by 2020, health care spending is estimated to rise to 21% of our GDP; or 1 out of every 5 dollars spent.

On the other hand, the World Health Organization recently ranked the United States 37th out of 191 countries based on health care performance.  Even more troubling is to look backwards and ahead; data show the U.S. health care system improving more slowly than that of other countries over time.

There’s no denying the numbers: We pay more, but get less — and those trends appear to be worsening.  Efficiency, as defined in context of health care, is achieving the best clinical outcomes at the lowest cost.  Bloomberg recently completed a study to determine the most efficient countries for health care, and it should come as no surprise that the United States ranked 46th out of 48 countries assessed.

Naturally, our path to greater efficiency must begin with accepting the concept of value in the health care equation, or the idea that our job as health care providers is to identify the right intervention for the right patient at the right price.   It may sound simple, but this is in fact in direct contrast to our natural inclination.  Here’s an example.

A few years ago, the United States Preventative Task Force made national headlines with its recommendation that women between the ages of 40 to 49 no longer need routine screening for breast cancer.  People were furious, and health care providers were conspicuously at the top of the list.  Not only are we trained to be empathetic, but in most cases, it comes naturally to us; it is, after all, what drew us to our profession.  We treat every patient as if he or she were our mother or our father (or son or daughter), ultimately giving that patient the best care possible.   Why, then, would I as a health care provider not want to screen my patients for breast cancer?  I certainly would want my Mom to be screened.

Here’s why: Roughly 1 in 1700 women screened between the ages of 40 to 49 actually ends up testing positive for breast cancer.  The overwhelming cost of the negative mammograms simply outweighs the cost of preventing the positive case.

For years, the United States has been the “spoiled rich kid” when it comes to medicine: We get whatever we want, without much regard to cost.  Now, we as health care providers are painfully aware that this approach hasn’t been successful and isn’t sustainable.   The Cadillac may very well take us where we need to go, but we must learn to take the Ford instead; it may very well get us there just fine, and at a lesser cost.

To spend less and get more, our medical decisions must be made based on objective evidence rather than subjective determinants like ritual, instinct, anecdotal information, and most powerfully, commercial influence.  Coined by Gordon Guyatt in 1991, the term evidence-based medicine refers to a decision-making process rooted in medical evidence.  The most commonly used definition today is taken from Dr. David Sackett: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.”

A recent study estimated that about half of the hundreds of thousands of drug-related deaths that occur each year are preventable, and more recently, it was shown that better information may have lead to better outcomes in the same environment.   A lack of “better information” may not point to a scarcity of good information- after all, we do live in the age of information- instead, however, it more likely points to our lack of reliance upon it.  The information is available; our culture as health care providers must evolve so that we habitually incorporate proven measures into clinical practice.

Returning to the concept of value, we as health care providers must continue to remember the concept of empathy, but realize that decisions must be made based on objective, evidence-based information.  We can no longer afford to act as the “spoiled rich kid”; we must continue to practice with our heart using emotions, but ultimately must make decisions with our brain using data.

Ashish Advani is a pharmacist and assistant professor, Mercer University College of Pharmacy, Atlanta, GA.  He is also founder, InpharmD.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I actually think we can and should be driving that Cadillac and most likely a much better model too.
    What we need to do is kick out all the entities inserting themselves into the medical care process just so they can steal large amounts of our health care money, and then have the audacity to lecture the American people about the need to face reality and dampen our expectations.

    BTW, I don’t think David Sackett would agree with using EBM as a bludgeoning instrument to override “individual clinical expertise” and push people into uniformly cheap substitutes for proper medical care:
    “Some fear that evidence based medicine will be hijacked by purchasers and managers to cut the costs of health care. This would not only be a misuse of evidence based medicine but suggests a fundamental misunderstanding of its financial consequences. Doctors practising evidence based medicine will identify and apply the most efficacious interventions to maximise the quality and quantity of life for individual patients; this may raise rather than lower the cost of their care.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2349778/pdf/bmj00524-0009.pdf

    • SteveCaley

      Unfortunately, the SRK syndrome is not particular to medicine. It is infused in the habit of American management techniques – we construct massive edifices of useless administrators to stand between the product and the consumer. Compared to the Soviet days, when their industry was saddled with Party and bureaucratic little bosses, they look like a model of efficiency to us now.
      The American manufacturing and industrial world is gone – there are hardly any non-Governmental customers who purchase civilian US products in the US. Once manufacturing, 40% of the US GDP in 1960, was the driver; now, our manufacturing for this market is perhaps 2%-3%.Very little is manufactured at home, except that which is too expensive to ship from overseas. Telephone poles – we still command the market in US Telephone Poles.
      It is one thing to give society a stern lecture on how to shape up or ship out. In reality, though, we are likely to taste a much more bitter lesson. We lack the domestic prosperity to engage in the niceties of culture – and, unfortunately, decent medical care is one of the niceties. Perhaps we can shear away the administrative and bureaucratic fleas; but they are notorious for letting the host die first. I think our target is Turkey by 2020 – Turkish healthcare will, in general, prevail in quality over our own.

      • DeceasedMD1

        Soon we will be unable to get our own rockets to the space station. I guess giving up producing in the US– the question was it worth it comes to mind?

        • SteveCaley

          Civilizations, like people, are robust for a while, then go infirm and sclerotic, and die. Suleyman had surprise and disappointment during his march through the walls of Constantinople when it fell to the dreaded Muslims. His army marched and marched through miles of empty suburbs inside the walls, some deserted for hundreds of years, ghost towns. The Byzantine Empire was still a fearful thing from the outside – but when the conqueror took it, it was nothing but a misty dream, a child’s tale.
          Sclerotic and dying cultures fall into the Dark Ages, and lose their ability to DO even the simplest things. We may still be strong, but we cannot stay the hand of political evolution; we can no longer go to the moon, and now even manned missions to space. It is the way nature takes its course in the ways of governments.

          • DeceasedMD1

            Wonderful diagnosis. So philosophical with a twist of medicine thrown in. I think there is truth that powerful governments die like people. The question is why couldn’t we have been around for it’s robust years?

    • ninguem

      Margalit, right on cue, here’s an article in the New York Times.

      http://www.nytimes.com/2014/05/18/sunday-review/doctors-salaries-are-not-the-big-cost.html

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Perfect.. I am glad the NYT is finally looking at what needs looking at. And it’s not just the compensation for these people. It’s the amount of useless work their sheer existence is generating for everybody else, driving costs up even higher….

  • QQQ

    “For years, the United States has been the “spoiled rich kid” when it comes to medicine: We get whatever we want, without much regard to cost. Now, we as health care providers are painfully aware that this approach hasn’t been successful and isn’t sustainable.”

    “The European Example: Rethinking Government-Run Health Care” by David Kinkade
    Mar 12, 2014

    Since the launch of Obamacare, Americans have begun to witness the reality of what more government intervention in the health care system means—burdensome mandates, tax increases, punitive fines, and heavy regulations.

    Yet at the same time Obamacare has created an expanded federal role in health care, other countries that have been operating government-run health programs for decades are furiously seeking to reform their dysfunctional and financially unsustainable systems before they unravel.

  • Steven Reznick

    What percentage of the health care dollar is spent on breast cancer screening to find that 1:1700 individual? Does the cost include breast self exam which is additionally advised against by the USPTF? Have you ever seen that 1 in 1700 woman die of breast cancer while her young kids and family tried to comfort her? Bad example for rationing.

    • Lisa

      I wonder if you are a radiologist?

      The recomendations of the USPTF have nothing to do with rationing or saving money; they are based on looking at the harm versus benefits of preventative tests.
      To find that 1 case of beast cancer does not significantly reduce the breast cancer death rate while many other women are harmed by unnecessary biopsies and overtreatment.

      • Steven Reznick

        I am an internist. If you believe the recommendation was not cost related then let me sell you a bridge between Brooklyn and Manhattan. While the end point survival may be no different with early detection, the treatment options for small lesions leads to far less invasive and complicated therapy than if the disease is well advanced when found . Those quality of life issues are largely ignored

        • Lisa

          At this point, the treatment for small lesions (low grade DCIS, for example) are as invasive as the treatment for small invsive cancers. Surgery and radiation have real side effects. Furthermore, many women opt to have more extensive surgery than is necessary, in part out of fear, in part because they do not understand their risk of developing another cancer. These quality of life issues are ignored by those who promote mammograms.

          Early detection of breast cancers has not reduced the death rate from this disease. Improvements in treatment have.

        • JR

          You know that many people have cancer when they die that was never detected, they never had symptoms, and it wasn’t a factor in their death?

          When a cancer is detected the knee jerk reaction is to treat it because “cancer” strikes fear in the hearts of the public. Our science is so poor we can’t tell which of the cancers are a problem and which can be ignored.

          “Early detection saves lives” is a lie. Early detection catches cancers that would never have been a problem to the patient.

          For example, this is a study that looked at prostate cancer of men who died of other causes. Look at how high the numbers are. And that’s just prostate, they didn’t look at lung cancer or colon cancer in this study.
          http://www.ncbi.nlm.nih.gov/pubmed/23847245

          I’ve read similar studies for other cancers. I also had two relatives that died of other causes, gave their bodies to science, and that’s the only reason we know they had cancer. It didn’t shorten their life or impact their quality of life – they are lucky no one ever found it while they were alive.

          • Mike Henderson

            1st paragraph – you are describing “overdiagnosis”, which can only be harmful for the patient. Unfortunately there isn’t a way to differentiate clinically significant from not clinically significant leading to paragraph #2.

            Paragraph #3 – early detection saving lives is certainly not true as often as publicized. I would add that screening is biased towards towards less aggressive cancers. Aggressive cancers tend to advance more quickly, leaving a smaller window to detect them.

          • NewMexicoRam

            Correct.
            The more I have been in practice, the more angst I see in regards to the finer points of health care.
            What do I mean? The major factors that have helped to improve human lifespans are good sanitation, immunizations, and antibiotics. After that, we are only talking about 10% of the issues that determine lifespan.
            If we want to make any real inroads into cancer, we need to stop spending so much on chemotherapy and radiation, and put the money into genetics, immunotherapy, and nanotechnology research.

          • Lisa

            Research dollars should be directed towards testing that will differentiate lesions that one should be concerned about and those that one should not be concerned about. I think medicine is beginning to do this. Onco type testing has changed the landscape with regard to chemo for early stage breast cancer. My oncologist recommended chemo therapy – oncotype testing revealed I would gain little advantage from it. Now they are developing similar testing for DCIS to indicate which cases require radiation and which can be treated by surgery alone.

    • Ashish Advani

      I can appreciate how difficult it is, but this is exactly the type of emotion we must remove from our healthcare decisions: Have you ever seen that 1 in 1700 woman die of breast cancer while her young kids and family tried to comfort her?

    • JR

      So, population studies say 1/133 people have celiac disease and more probably have non-celiac gluten sensitivity and will show up negative on testing. 85% or more are un-diagnosed. Screening can be done with a blood test now.

      So why aren’t we population screening for it?

      Blood tests aren’t generating anyone money.

      The treatment “dont eat gluten” isn’t generating anyone money.

      Oh.

      But there are a couple drugs in the works… why do I have a feeling that when those drugs become FDA approved that screening for Celiac will become a thing?

      • Lisa

        I had no idea celiac desease was so prevalent, but I disagree with you that not eating gluten isn’t generating anyone income. It many not generate income for doctors, but gluten free foods are becoming a big business. Look at the wide range of gluten free food products that are available now. Such a wide array wasn’t available five to ten years ago. What cracks me up is food that never had gluten, such as corn chips, now tout the fact that they are gluten free.

        • JR

          Flour stays in the air for 48 hours after you’ve stopped processing it. So if corn chips are made in a facility that also processes flour, they aren’t gluten free.

          Recent guidelines require that grocery store food that claims to be gluten free HAS to actually be gluten free… this isn’t true of restaurants yet.

          I think the food industry isn’t going to have a lot of sway in screening in the same way medical groups, large hospital systems, or pharmaceutical companies do.

          There are a few drugs for celiac treatment that are being “fast tracked” by the FDA, I have a feeling that if they get approved (early trials are promising) that screening may become a reality.

          Of course… if the drugs really work as expected then I want them to be approved, I’d definitely benefit.

          • Lisa

            I’ll have to start paying more attention to the labeling on gluten free food. A lot of times I notice something along the lines of this food was prcessed in a gluten free facility.

            I think I’d rather eat a gluten free diet than take a drug to treat the celiac. It isn’t that hard, imo, and I suspect any drug would have side effects.

          • JR

            The one they are doing is basically like “Lactaid” for lactose intolerance or “beano” for beans. It’s a digestive aid.

            It’s hard to be 100% gluten free, especially if you eat any food that your friends make. For instance, my friend made a bunch of sandwiches for a picnic, and lettuce wraps for me. She made the lettuce wraps on the cutting board she made the sandwiches on.

            All it takes is about 1/48th of a piece of bread to cause damage. Some 70% of people with celiac can’t stick to a full gluten free diet.

          • Lisa

            Would a digestive aid allow you to eat a large amount of gluten or allow you to tolerate a small amount?

            I don’t have problems with gluten, but avoid wheat as I may have a mild intolerance to wheat. At least that isn’t hard, as long as I avoid processed food.

          • JR

            It wouldn’t allow people to actively eat gluten, just protect against accidental digestion, like cross contamination at a restaurant.

            I believe they are starting Level III trials soon: http://www.ncbi.nlm.nih.gov/pubmed/24583059

            Of course, there are some other drugs in development too.

  • Mike Henderson

    When in residency, we were taught the process to practice evidence based medicine. You start with the patient’s problem, generate a useful question and then search for the latest pertinent articles and try to apply the studies to the degree the patient matches the patient populations studied. Its certainly not perfect, but in certain difficult situations, it’s the best there is.

    My opinion is that EBM is a good tool. It should improve care, but doesn’t really have anything to do with evaluating cost. In certain cases it will lower costs and others will raise costs. Overall, it could raise costs, and as the author asserts, should improve value. When it comes to cost evaluation, EBM can shed some light, but doesn’t indicate whether the costs are worth it or not. How much we are willing to pay for something is up to society to answer.

    That I can tell, most laymen (politicians, insurance companies) misunderstand EBM. They think guidelines are equivalent to EBM because the guidelines use the latest research. The two processes are very different and can easily come to different conclusions for the same patient. Guidelines are for populations until the next updated guideline comes out and really only answer a few questions regarding optimal patient care. Guidelines should not be confused with rules, as they seem to be in the ACA. EBM, as I have been trained, is focused on an individual, at a given point in time, with a specific problem and is much more versatile when guiding care. EBM in its true form, will not be understood by politicians or insurance companies.

    • rbthe4th2

      Its a pity that a number of my docs didn’t know EBM. I found out the truth from EBM. At least it helps me to separate some of my docs from others.

  • JR

    It’s not “cost” of unnecessary treatment isn’t in dollars it’s the HARM to all the women with unnecessary treatment and procedures due to over screening.

    THAT’s why the recommendations are to scale back. It’s important to understand when the harm outweighs the benefits.

    • Lisa

      And the reason the recommendations of the USPSTF are not being reflected in practice is due to the intense reaction of the radiologist and those who profit from breast cancer screening.

      • JR

        I remember reading that when someone is screened for something, and they have a false positive, they tend to believe in screening MORE strongly, and encourage people to do it, even though they were one of the people “harmed” by screening. There was a book written about it but I can’t remember the title. But that’s part of the reason people have embraced screening and don’t want to give it up.

        • Lisa

          And the other issue with mammograms is that many women who were diagnosed with DCIS feel that the mammgram saved their lives and become strong proponents. Hence the tee shirts emblazoned with slogans like ‘These are fake, the real ones tried to kill me’

          The truth is fare more complex and can’t be reduced to slogans.

          • JR

            I know someone who had a total hysterectomy for pre-cancerous cervical cells – CIN II. I’m sure she didn’t know that:

            “In those with moderate dysplasia (CIN II), 16% will advance to severe dysplasia within 2 years and 25% within 5 years. An overall progression rate of severe dysplasia (CIN III) to cervical cancer was observed in 12% to 22% in other studies.”

            Wouldn’t she have benefited from watchful waiting? She feels her treatment was fully justified and the best thing to do.

            This is the harm of over-screening.

  • Ashish Advani

    To be clear, I’m not advocating for removal of clinical expertise in decision-making, but am in favor of aligning more decisions with evidence–which I believe will lower cost and increase quality. It used to be that decisions were solely based on what the physician already knew, but in this age of information (and the internet), there’s no reason to continue this way.

  • Karen Ronk

    Making decisions with our brains using data….. interesting concept. This has become a lost art throughout all of society and with all professions. It is more like fill in the blanks then formulate a response. If the response is incorrect or inadequate, oh well. Next, please.

    Whether it is the inability to listen or to comprehend, I really do not know. But I seem to have more and more interactions with people who have many more years of education than myself who cannot comprehend what I say or what my needs or situation requires. Doctors definitely included, but not exclusively.

    Maybe there is an app for that – or maybe I should invent one.

    • SteveCaley

      I believe that these are all symptoms – cognitive and processing failures that are not from neurofibrillary tangles, but still result in the failure of executive function, on a societal level.
      ” It is more like fill in the blanks then formulate a response.” Yes. People avoid thinking at an adult human level; rather, think as automatons. “I will help until I arrive at a ‘fail-state’ and then cannot help you any more, sorry, come again!”
      Our greatest danger is not the emergence of silicon thinking machines, but the decline of the carbon-based ones. We idealize the silicon mind, believe that it can rescue us from our failures; it can’t.
      There are far too many powerful forces with skin in the game of evidence-based medicine, to risk all the findings to the turn of the dice. Don’t bet much on the game.

  • PoliticallyIncorrectMD

    So called “evidence” you advocate for using are extremely biased, incomplete and change as often as fashion. How about we start with looking for evidence that evidence-based approach saves money or improves outcomes. Are you aware of any?

    The bulk of the US health care spending has nothing to do with actual cost of diagnosis, treatment or providers’ salaries. Most of it is third party profits, supporting overinflated bureaucratic apparatus, complying with useless mandates and regulations and practicing defensive medicine. How about we start dealing with real problems, not the imaginary ones!

    • Ashish Advani

      Yes, and this could be an article in and of itself! Decision trees, utility theory, Bayes theorem for analyzing diagnostic tests, mathematical models, cost-effectiveness analyses, outcomes management, and meta-analyses all strengthen the argument for bringing more evidence into decisions.

      Specifically, my expertise is in electronic knowledge resources designed to facilitate point of care learning; here are some that demonstrate improved knowledge and associated patient
      outcomes:

      Reed DA, West CP, Holmboe ES, Halvorsen AJ, Lipner RS, et al. Relationship of electronic medical knowledge resource use and practice characteristics with Internal Medicine Maintenance of Certification Examination scores.
      J Gen Intern Med. 2012; 27: 917–923.

      McDonald FS, Zeger SL, Kolars JC. Factors associated with medical knowledge acquisition during internal medicine residency. J Gen Intern Med. 2007; 22: 962–968.

      Isaac T, Zheng J, Jha A. Use of UpToDate and outcomes in US hospitals. J Hosp Med. 2012; 7: 85–90.

      Bonis PA, Pickens GT, Rind DM, Foster DA. Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the
      United States. Int J Med Inform 2008; 77: 745–753.

      • PoliticallyIncorrectMD

        Your sources suggest that more knowledge is good. There is no question about it! What I am arguing against is separating the knowledge into “good / high quality” and “not-so-good / poor quality”. By the way, Medicine is the only branch of science that accommodated this approach which is philosophically and methodologically flawed. Knowledge is not limited to randomized placebo controlled clinical trials and meta-analyses. Knowledge also includes understanding underline physiological / biochemical disease mechanisms, personal observations and intuition (yes, INTUITION, deemed by some philosophers of science to be the highest, most sophisticated form of knowledge). As long as we deny this complexity of Medicine and science in general, we are doomed to failure.

  • ninguem

    Problem with the “spoiled rich kid” analogy, is the person acting like the “spoiled rich kid”, is usually trying to act spoiled with some else’s money.

  • DeceasedMD1

    I think there is a huge disparity in HC. Not everyone is spoiled rich kid syndrome. Many people don’t have the means to affordable HC for basic PC problems, even after the ACA. Medicine used to be an art and evidence based does not answer all the problems. There is a big push to act with procedures for financial gain than to allow time to think about the most logical treatment plan. I do not think “logic” and “evidence” based will solve the problem since many tests offered are about increasing revenue for the hospitals etc. commercial gain as you said.. No amount of evidence will change that approach. The commercial factors at play are too powerful. Until we can change that no amount of evidence will change these practice behaviors.

  • ninguem

    I’m not prepared to change my mammography recommendations based on the criticized studies.

    The practical problem as well. If I recommend annual mammograms, they will get done, in reality, every two years.

    If I recommend every two year mammograms, they will get done, in reality, every five years.

    • Lisa

      The current recommendations of the USPSTF have nothing to do with the Canadian study, ak123 is referring to. The recommendations were made long before the Canadian study was published.

  • Lisa

    The USPTF does not consider costs. From their web page on Prostrate Cancer Screening:

    The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

    • Steven Reznick

      These are complicated issues that need to be personalized with the pros and cons discussed with the patient well in advance. No screening test is perfect and all can result in false positives requiring additional testing. All can result in false negatives missing malignancies. These are the risks of screening. Sometimes you do find an unexpected finding such as a low grade indolent B cell lymphoma on a screening mammogram in a 68 year old who is by nature very anxious.
      The American Cancer Society presents data from 7 randomized control trials of screening mammography that there is a 22% drop in mortality in screened women between 50 – 75 years old. They say that 70% of imaging detected cancers are stage zero . They also say 71% of deaths are in unscreened patients. They additionally admit that basic analog mammograms find a cancer in only 1-2 of 1000 screened. Mammograms do not make radiologists profit. They are labor intensive, high liability but a necessary part of a imaging process. As you add digital, 3D and contrast enhancement plus ultrasound , tomboys thesis, molecular breast imaging and MRI in the correct patients,their accuracy and cost increase.
      you need to seek out an experienced women’s center, with both. Anatomical and biological imaging capabilities. Experienced radiologists aided by first identifying high risk individuals personalize the screening based on age, genetics, breast density and other factors. This is fruitful but certainly not cost angst and error free mammographic screening I am referring to.

      • Lisa

        The USPSTF recommends biannual screening mammograms for women in the age group you mention. 50 to 75. Furthermore, they say the decision to start screening in younger women should be an individualized one. But the ACS guidelines go well beyond the recommendation of the USPSFT. I wonder why? The ACS recommendation on screening for prostrate cancer is more in line with the USPSTF recommendations. I wonder why ?

        I know that screening for breast cancer is complicated, but one has to wonder about professional groups protecting the interest of their memebers when their screening guidelines are out of line with those of a group such as the USPSTF, who look at the harms versus benefits of preventative tests.

        • Steven Reznick

          You have more faith in USPTF than I do. They are federally funded and we have had several administrations trying to reduce health care spending. I do not believe they are as impartial as they portray themselves to be.

          • Lisa

            When a professional groups recommendations for screening calls for more extensive screening than is recommended by a group who studies the evidence I am uncomfortable with the motive behind the professional groups’ recommendations. Again, I ask the question why is the ACs recommendations for screening mammograms different from the USPSTF when their recommendations for prostrate cancer screen are in line with those of the USPSTF?

    • doc99

      Errr… PROSTATE

      • Lisa

        I found the misspelling and corrected it. Spell checkers don’t work too well when your error is another word, spelled correctly.

  • https://www.facebook.com/arobert6 Alice Robertson

    When you say “recently” WHO released these stats….can you share the date (I thought the data was from the year 2000)? I thought WHO decided long ago not to release stats like this again because it was found they weren’t done on a level playing field?

    • Ashish Advani

      Yes, sorry, it’s 2014, and I should’ve hyperlinked this in the article: World Health Organization. Measuring Overall Health System Performance
      for 191 Countries. Available at: http://www.who.int/healthinfo/paper30.pdf.

  • ErnieG

    This simplifies the problems with screening. Not only do you want a test that performs well (good sensitivity, specificity, and predictive values), but that provides clinically relevant information which will improve patient
    care. The problem with prostate cancer screening is not so much the problem of false positive results for prostate cancer, but rather that is detects prostate cancer which will not harm the patient, leading to treatment which harms the patient. In other words, the biology of cancer is important, and as we all know, not all cancer is the same. The idea that early detection of cancer will lead to improved outcomes is one that sounds appealing, but should not be taken as fact. I am not convinced at all that “breath tests and blood tests … to detect all kinds of cancers at very early stages and at minimal cost” will actually lead to better medical care, nor that “cancers [that are found] earlier” will lead to “treatments [that] will be less drastic and
    cost less.”

  • Lisa

    I think the concern regarding screening for breast cancer is much more involved than the problems of false positives.

    Increased screening for breast cancer has led to more case of in situ cancers (DCIS) and early stage cancers being detected. It has lead to more women receiving treatment. But increased screening has not led ot a drop in the number of breast cancer deaths, as you would expect if early detection actually reduces mortality. But, in most cases, the biology of a woman’s breast cancer is more important in determing her prognosis than when the breast cancer is actually detected.

    You say that if cancers can be found earlier, treatments will be less drastic and cost less. Well, at this point medical science can’t determine which cases of DCIS will go on to become invasive (approximately 25% will) and which could just be monitored. So for now, the standard of care calls for evey woman who is diagnosed with DCIS to undergo the same treatment she would if she were diagnosed with an early stage invasive cancer. That is a real harm and has to be weighed against the benefits of screening on a population basis.

  • Ashish Advani

    It does, and I don’t want to minimize expertise as important in the decision making process. But, it shouldn’t be the only factor (as it currently oftentimes is), and I believe the more objective information included in that process, the sooner our quality goes up and our costs go down.

  • Patient Kit

    Consider the source. Didn’t he also believe that if the rich got richer, it would trickle down to the rest of us (instead of widening the gap and just making the rich richer and the poor poorer and putting the middle class on the threatened species list )?

    Trust me, there are scarier words. For example: “You have cancer. What kind of insurance do you have?”.

    In my case, my government was there for me this year, in the form of Medicaid, which functioned as a safety net and saved my life by allowing me to have life-saving surgery when my cancer was first found at an early stage. Medicaid covered and is still covering excellent medical treatment at a NYC teaching hospital, where I’m in the care of the best doctor I’ve ever had. Government help was much better than the alternative of delaying treatment until I stabilized financially and had enough money and a new insurance plan. Sometimes we need help pulling ourselves up by our bootstraps.

  • rational2012

    You wrote: “The overwhelming cost of the negative mammograms simply outweighs the cost of preventing the positive case.”
    Gee whiz. I was not aware somebody knew how to prevent breast cancer. Do they do that in India? Why don’t you tell us how it is done.

  • Patient Kit

    I have Canadian friends who have gone through cancer treatment in their healthcare system and they did not experience the situation you describe. They did not die, a mere statistic, while waiting for treatment. They got good treatment in a timely manner.

    • Lisa

      And I have talked to many women who have gone through cancer treatment in Canada and England. In both countries, they didn’t have to wait for treatment. I do know people in the US whose cancer treatment has been constrained by their financial situation.

  • Malcontent

    I believe it, my employer just stuck me with a 158 dollar a week health plan for my family-and we hardly ever go to the doctor. I would love to have a higher deductible but have no choice, take it or leave it. that’s about 12 % of total pay going to something I rarely use.

    • Ashish Advani

      Amazing, isn’t it? That’s one 1 of every 5 dollars we spend, spent on healthcare.