July 17, 2018 | ° F

Health rationing can have benefits

One of the key criticisms of increased government involvement in health care is that it will seek to cut costs by denying access to routine procedures that Americans have relied on for many years to diagnose harmful conditions ranging from heart abnormalities to colon cancer. Denial of access would indeed help to curb the explosive rise in national healthcare expenditure, but a judicious rationing of procedures can do much more than that — it will cut down greatly on unnecessary pain and suffering from overtreatment.

Let's use the prostate-specific antigen (PSA) test for illustrative purposes. This particular diagnostic procedure screens for prostate cancer in men by measuring the level of PSA in the blood. PSA is a protein that is produced in the prostate, and an elevation of its level above a certain threshold raises suspicion of prostate cancer and commonly leads to follow-up tests and procedures. Introduced in the late 1980s, PSA testing is currently recommended annually in men over 50 years of age as well as those who are younger but have certain risk factors for developing the disease.

For all its benefits in detecting aggressive prostate cancer early in certain individuals, the current sledgehammer approach to prescribing PSA tests for the entire above-50 population is not without costs. For one thing, the test has a 75 percent error rate. That's right: Only one in four men who have a positive (abnormal) PSA test actually have prostate cancer.

How can this be? The reason is that PSA levels can be elevated by conditions other than cancer, including infections and benign prostate enlargements. In addition, the most aggressive prostate cancers may not cause an elevation in PSA levels at all, leading to crucial missed detections.

Also, most prostate cancers are slow growing and never affect an individual during his lifetime. In fact, 80 percent of men aged 80 years or older have prostate cancer. Simply put — a person is much more likely to die of old age with prostate cancer than as a result of the disease.

Two landmark studies published in the New England Journal of Medicine last year support the notion that PSA tests are of limited use at best. Both studies randomly assigned men to either the PSA testing group or the non-testing group and recorded prostate cancer-associated mortality for the next decade.

The first study found no difference in mortality rate between its two study groups, but the second study found a 20 percent relative decrease in mortality in its testing group. Although the results of the latter study may appear to vindicate supporters of this procedure, it also showed that for every life saved from prostate cancer in the decade following a positive PSA test, 48 men undergo needless treatment for non-aggressive cancer. That means only two percent of those treated actually benefit from the testing.

I can already hear the rhetorical question invoked by this last statement: "What if it was your relative or friend who fell within this two percent?" Well, if the other 98 percent suffered no ill harm from the unnecessary diagnosis, then I would concur that a two percent efficacy, while small, is still worth it. But that is not the case. Besides suffering from increased stress and anxiety due to the diagnosis, this other 98 percent are put through rounds of unnecessary surgeries and radiation treatments that often lead to severe and permanent side effects such as impotence, incontinence, and chronic diarrhea. That is to say nothing of the billions of dollars associated with these overtreatments.

With the facts being so clear against such widespread use of PSA testing, it is a wonder why no official change in testing guidelines has been adopted yet on a national level. Such a change would promote rational rationing by moving away from the sledgehammer, age-based approach to more of a scalpel approach, thereby limiting the diagnostic function of PSA tests to those who are at high risk for developing aggressive prostate cancer, as determined by their physicians. These groups — including blacks and those with family histories and certain genetic mutations — are the ones that truly benefit from this procedure.

Sadly, the PSA testing industry, the current reimbursement system, and "death panel" disciples have ensured that the status quo of overdiagnosis and overtreatment is maintained. As Richard J. Ablin, the discoverer of PSA, lamented recently in an opinions piece in The New York Times, "I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster."

Judicious rationing can be extended well beyond PSA tests. For instance, with mammography, which is used to detect breast cancer, the same sledgehammer approach is currently being employed — all women are encouraged to begin annual testing at 40 years of age, with those who are at high risk beginning much earlier. While breast cancers are often more aggressive than prostate cancers, 10 women still receive unnecessary toxic treatments for every life saved due to mammograms.

During the heat of the health care reform debates last November, the U.S. Preventive Services Task Force came out with the evidence-based recommendation that annual mammograms for those without risk factors begin 10 years later and occur at half the frequency. Adopting this guidance would have moved us in the right direction, but the irrational firestorm that it created was so great that the President Barack Obama administration was forced to quickly distance itself from the Task Force to prevent the likely fabrication of "cancer panels" and the further stalling of health care reform.

In order for any judicious rationing of health procedures to be effectively implemented, the White House has to shift the physician reimbursement system away from the piecemeal, fee-for-service system that rewards doctors for over-prescription of diagnostic procedures to a base salary system that offers bonuses contingent on patient well-being criteria. This will encourage more physicians to start a dialogue with their patients about why more medicine does not necessarily equal better medicine.

The administration will then have to take the crucial step of actually enforcing the rationing by revising the insurance companies' required baseline coverage, starting with Medicare and Medicaid and gradually expanding outward. This will be an ongoing process that will allow for more optimal use of procedures and tests as more and more research data streams in.

When asked at a press conference last July about the sacrifices that Americans will have to make for health care reform to be a true cost cutting measure, the president responded, "They are going to have to give up paying for things that don't make them healthier. And I — speaking as an American, I think that's the kind of change you want."  Agreed. Now it's time to walk the walk.

Bo Wang is an Ernest Mario School of Pharmacy fifth-year student and president of the Pharmacy Governing Council. 

Bo Wang

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