May 08 2009

A Word on Cost-Effective Medicine

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Comments: 13

My post from yesterday sparked a lot of discussion about the cost-effectiveness of medicine. This is a deceptively complex topic, so I thought I would discuss it briefly today.

Essentially what cost-effectiveness means is the most bang for the health care buck.  If you want to read up on how this concept is applied in detail you can read this open-source online course from Johns Hopkins. This give an overview of the current system for quantifying cost-effectiveness.

The system considers quality of life years – how many years of life at what quality will how many people have without and then with a specific intervention. Is the expense of that intervention worth the increase in overall quality of life years? For these calculations, everyone is treated equally. Quality of life is very subjective, but there are ways to pseudo-quantify it, such as surveys about depression, pain, mobility, independence, etc.

Of course this system is most useful when comparing two interventions. It is easier to say that intervention A increases quality of life years per dollar spent more than intervention B. It is a societal judgment call to conclude that the exepense of treatment A is worth it in absolute terms.

There are some further concepts to consider regarding cost-effectiveness. It is possible for a placebo to result in an increase in quality of life years. If placebo effects result in a decrease in reported pain, that will result in an increase in quality of life years, and therefore the calculations may say the intervention is cost effective (especially if it is a cheap placebo). This is why cost-effectiveness calculations are not sufficient to say that a treatment works or that it is worthwhile.

Any placebo intervention may seem cost effective if just the direct costs and results are looked at. However, confusing a placebo treatment for a physiologically active treatment causes much downstream mischeif. It diverts research and clinical dollars away from effective modalities. It creates public misunderstanding of the nature of health, disease, and biology which likely has an adverse effect on future treatment. It erodes the healthcare system from within.

That is why I always cringe when I see a cost-effectiveness study on a treatment that has not already been demonstrated to work. This is a worthless exercise, used only for the promotion of ineffective treatments (no more effective than placebo) based upon unscientific notions.

Regarding the question of whether or not an intervention is objectively worth it (rather than more or less cost-effective than another intervention), the almost universal answer from the public is – yes! If it works, people want it. This is a reasonable position from an individual perspective, but not sustainable from a societal point of view. We already have the technology to deliver more health care than we have the money to afford. Health care costs are increasing, mainly due to technological advances.

But when it comes to health care, everyone is a narcisist. Everyone wants the best for themselves and their loved-ones, regardless of the cost to society.  I wish we could afford the best for everyone, but we can’t. That is why there is no simple solution to our current health care crisis. We have to ration, but there is no political will to.

We have the technology is some cases to deliver extremely expensive interventions for real but marginal benefit. When it’s your life, you want the benefit. But the costs are cripling. Sometimes we just have to say, it’s not worth it. The people who are saying this are the insurance companies – including the most draconian insurance company of them all, the government via Medicare and Medicaid.

I think the long term solution to this dilemma is to focus research on finding more cost-effective treatments, and not spend time and money researching very expensive interventions we can’t afford anyway. There is already a move to do this, but I think we need to emphasize it even more. We should be looking at the most expensive interventions and trying to find less expensive alternatives.

But of course, they have to be alternatives that actually work.

It is also worth pointing out that cost-effectiveness is not equal to the cheapest treatment. As someone pointed out in the comments yesterday, the cheapest interventions are those that result in people dying quickly. Interventions that keep people alive are expensive simply because they keep people alive to consume more health care in the future.

But remember, cost effectiveness is about increasing quality of life years. If someone dies young, that is a negative cost-effectiveness, even if it is cheaper.

We have some tough choices ahead for our health care system, primarily driven by the primary dilemma that we can deliver more health care than we can afford. Modern health care is the victim of its own success. There is no simple solution. But redirecting clinical research toward more cost-effective options will help.

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