Friday, August 14, 2009

Krauthammer on preventive healthcare

In a recent column "The inconvenient truth about preventive care" (8/14/09), Charles Krauthammer claims that evidence shows that preventive medicine will not save money in overall healthcare costs. He gives an example of a test which costs $500 and can save $10,000 in later expenses when it gives a positive reading. He argues that when 1 in 10 people have the disease, the overall savings are real, but when only 1 in 100 will test positive, the overall expenses of giving the test to the 99 out of 100 people who don't have the disease result in a large net loss. This reasoning is not, in general, correct; here are several reasons why.

1. Not everyone gets any particular test. Patients are generally screened before being given expensive ones that detect rare diseases. Children and young adults are rarely given colonoscopies; generally healthy people are not routinely given chest X-rays, CAT-scans or MRIs. Mammograms are recommended on the basis of age and estimated risk.

2. Some tests can detect several diseases very early. For example, a single routine blood or urine analysis can detect many different incipient diseases such as anemia, bladder infection or diabetes. Without a healthcare program providing such a test for an appropriate group of the population, these easily-detectable diseases would go unrecognized until they became serious and expensive to treat.

3. The ratio of $500 of prevention to $10,000 of cure is extremely simplistic. I'm sure that Krauthammer knows this, but as a single example it is very misleading. Take the case of diabetes, where the detection by a routine blood test (and follow-ups in the case of a positive result) is fairly inexpensive. The cost of untreated diabetes is far greater than $10,000. Severe diabetes often leads to blindness and amputation; does anyone think that a pricetag for such an outcome is merely $10,000? Furthermore, in that segment of the population where the risk of diabetes might suggest a non-routine screening, the expected proportion of positive diagnoses is far higher than 1 %.

More generally, how do we assess the true cost of a disease? Is it simply the treatment? When we ask about the finances of a late detection of breast cancer, do we talk simply about the costly radiation and chemotherapy, or do we also add in the lost wages during treatment and the expenses, such as daycare, resulting from unsuccessful treatment?

4. In the context of non-universal health-care -- which is what we have now -- the costs of uncovered disease is much greater than Krauthammer acknowledges. A person suffering, for example, from severe chest or stomach pain but who doesn't have medical coverage, will typically go to a hospital emergency room. Such a visit typically costs hundreds if not thousands of dollars, irrespective of what is detected or what treatment is indicated. On the other hand, a person with a health care plan would typically visit a primary-care physician who would know that person's history and direct that person's care to the appropriate specialists if needed. Expensive emergency-room care would be reserved for cases of critical trauma -- which is what they were designed for.

In any case, Mr. Krauthammer misses the point of the healthcare issue. Healthcare will not "pay for itself": no one ever suggested such a thing. However, it is well-established -- beyond debate -- that it is possible to provide universal healthcare that is far better in outcome than anything we have here in the U.S., and at a cost far less than what we currently pay. How do we know that? From statistics, projections, medical or economic theory? No. We KNOW this because most of the developed countries of the world already do it. Furthermore, they do it with LESS "rationing" than we have currently within our for-profit system. A large fraction (maybe 1/6 and increasing) of our population is already rationed out because they simply have no coverage. Of the remaining, nearly everyone already experiences rationing. Almost no one can choose any doctor and any procedure at any time. The insurance companies simply don't allow it. Furthermore, many millions of people with coverage have their care rationed by the large deductibles and co-payments. Sure, Canadians may have to wait months for a hip replacement; but, you don't get one here if you don't have coverage, and even with coverage you'll probably have to pay some and wait some.

In France, for example, which has a hybrid public/private plan, everyone has basic coverage for preventive care and most illnesses -- similar to the coverage that most Americans with healthcare now have, minus the deductibles and copays. For those who want to chose any doctor for any procedure at any time, they can buy an extended plan through private insurers -- for which they pay extra. France has a higher life-expectancy and lower infant mortality than we do, and people there love their healthcare system.

We know that universal healthcare is achievable since it has been achieved over and over again. Any theory that says it can't be done cheaper and more effectively than the way we do it now is proved simply wrong by the facts "on the ground" as they say in the military.

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