Today's Boston Globe revisits the question of whether screening (vs. other forms of prevention) is a cost-effective approach to improving health care. Obama has called for more screenings; the CBO and folks like Peter Neumann, Director of the Tufts Center for for the Evaluation of Value and Risk in Health, continue to point out that increased screenings alone will increase, not decrease, health care expenditures in the long run, thus running against the President's budget-neutrality mantra.
But prevention is about more than screenings. See my recent post regarding the value of prevention, citing Ken Thorpe (also quoted in today's Globe article). Prevention would not be at the core of employee health programs at companies like IBM if it didn't save some serious money. Best estimates peg the ROI at about 400%.
Neumann and Thorpe are both right; they're just answering different questions. A key issue for the future will be defining effectiveness for purposes of comparative effectiveness research. Key issues in that exercise include valuation of human life (never an easy task). See my post on the QALY issue following up another article in which Neumann was quoted, over two years ago.
Finally, tort reform is a red herring: The cost of medical errors is about three to five times the cost of all malpractice insurance premiums, so where's the malpractice crisis (other than in MSM headlines)?
Update August 19, 2009: See more discussion on tort reform in the comments, and see also The Washington Independent's roundup of reasons why tort reform is unlikely to cut health care costs.
The challenge with screenings is to mandate or cover only those which are highly predictive, have few false positives (which lead to additional testing for someone who turns out to be healthy), and screen for disease we can treat effectively. Oh, there it is again, the "e" word. Let's hope the comparative effectiveness research structure is adequately funded in whatever health reform legislation gets enacted (well beyond the pittance allotted in ARRA), so that this can be addressed in a meaningful way.
David Harlow
The Harlow Group LLC
Health Care Law and Consulting
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David,
I follow you closely and find you are on target 99.999% of the time but you missed it on tort reform. It is a sine qua non.
If you want to rid the world of premiums – you are correct. But that is not the point. It is the wasteful defensive medicine. See my blog at http://surgeonshealthpolicy.blogspot.com and refer to the piece on tort reform.
Patients have a right to sue and they should when concern over wrongful is raised. But the judgments are oftentimes settled based on a lack of evidence, a lack of understanding of the expert testimony and funny legal words.
To avoid the minefields of the court room, so many physicians just over order unnecessary clinical care and bill it to the patients and the insurer rather than take a chance with an ill informed judge or juror. The result is an overuse of billions upon billions of dollars. It is unquantifiable but every physician will tell you that we practice both evidence based medicine and defensive medicine.
Until we have safe harbors for evidence based medicine which is used in performance measurement – no right minded physician would take a risk at doing only the right thing, if it meant they could be wrongfully sued and lose their credentials to practice.
What would happen if attorneys were removed from the bar for not doing every thing possible, filing every possible motion – despite its silliness? You would file every motion and bill the client. Why take professional, career destroying risks.
Yes, tort reform is absolutely critical – and it is not related to premiums as much as it is to creating safe harbors to allow for us to rid the world of defensive, wasteful medicine.
Frank —
Thank you for your comment.
I understand your point, and perhaps I was using too much of a shorthand approach re: tort reform. I’m well aware of the defensive medicine issue, but that would be addressed in a number of ways in a “new regime,” e.g., by adoption of protocols developed through comparative effectiveness research, thus establishing new standards of care against which malpractice claims would be judged.
A somewhat related point: We always hear about the outrageous jury awards; the media is not as interested in covering reductions of insane awards by judges, or negotiated settlements entered into in lieu of protracted appeals.
Finally, the data in the Public Citizen materials linked to in the post are worth checking out.
Even if we assume that “defensive medicine” exists and can be quantified (and I do not agree with the tactic of taking the largest and most exaggerated figures and throwing them out as if they’re gospel), important questions remain:
1. Can any actions short of 100% immunity diminish the practice of “defensive medicine”? By way of illustration, Texas enacted “tort reform” that comes pretty close to that goal – did the new laws also eliminate “defensive medicine”? Did its “practice” diminish?
2. What system could replace the current malpractice system without maintaining or increasing the problem of “defensive medicine”? For example, some proposals try to squeeze plaintiff’s lawyers out of the picture – due process issues aside, that’s likely to vastly increase the number of claims presented against doctors based solely on outcome.
As is demonstrated by a relatively recent study published in the NEJM ( http://content.nejm.org/cgi/content/full/354/19/2024 ), the problem of “frivolous lawsuits” is largely imagined, and to the extent that lawsuits are filed that are determined not to have merit the problem is the defense tactic of “delay, deny, defend” – “The profile of non-error claims we observed does not square with the notion of opportunistic trial lawyers pursuing questionable lawsuits in circumstances in which their chances of winning are reasonable and prospective returns in the event of a win are high. Rather, our findings underscore how difficult it may be for plaintiffs and their attorneys to discern what has happened before the initiation of a claim and the acquisition of knowledge that comes from the investigations, consultation with experts, and sharing of information that litigation triggers.”
Aaron – We’re on the same side of the Texas issue: Tort reform didn’t solve the problem. The “problem” — both malpractice litigation and award/settlement costs, and the expense of defensive medicine — also happens to be such a miniscule percentage of the total health care spend (on the order of 2%) that I’m not sure it deserves separate attention. Rather, in the manner that the recently-announced demonstration projects are headed (see http://bit.ly/h7wzR), we should look at ways of improving patient safety, improving communication between patients and docs, ensuring appropriate compensation where warranted, reducing frivolous lawsuits, all of which are important ends in themselves and will also result in lower premiums.