Getting the Health Care You Pay For

There was a good front page article in yesterday’s Washington Post on the history of advances in medical science and technology.  The conclusion:  Although the costs of treating many serious medical conditions has risen dramatically over the course of the last few decades, most of these cost increases have come hand-in-hand with significant improvements in health outcomes.  Take the article’s discussion of the evolving treatment of heart attacks:

“When I was in medical school, about all we had to offer was oxygen, morphine and prayers,” said Eric Topol, director of the Scripps Translational Science Institute in La Jolla, Calif.  Topol, who turned 55 last month, graduated from medical school in 1979. For 15 years he was head of cardiology at the Cleveland Clinic, where he helped run some of the clinical trials that have changed treatment so dramatically.  Today, someone having a heart attack who gets to a hospital in time is likely to get cardiac catheterization, angioplasty, the placement of a medicated stent, therapy with four anticoagulant drugs and, on discharge, a handful of lifetime prescriptions.  “There’s been a complete transformation in how it’s handled just since I’ve been in medicine,” Topol said.  That transformation has saved the lives of millions of Americans.

Of course, not every costly intervention works as well as the others.  Drug-eluting stents cost from $600 to $1,000 more than bare metal ones, but only provide a very small advantage.  The question is:  Who gets to decide whether the expense is worth it?  With millions of additional Americans about to be brought into taxpayer-subsidized or paid health care systems, we naturally want government to make wise spending choices.  But health care reformers who want to give government bodies greater power to deny health care choices over-simplify the ability to make these decisions.

President Obama, for example, has been characterizing the comparative-effectiveness concept as simply as choosing between two drugs, one of which works better than the other and costs half as much (You can watch the President on YouTube here).  But, like the drug-eluting stent example, most (thought admittedly not all) health care choices boil down to more costly interventions working very much better for some patients and providing little or no benefit for others. “It is safe to say that almost everybody who has a heart attack wants the best treatment available. Nobody wants to turn back the clock,” the Post article acknowleges.  But, for the Administration, there are no hard choices:

“No part of health reform is talking about rationing who gets this care and improvement in treatment,” said [David] Cutler, the Harvard economist, who is one of President Obama’s principal advisers on health care.

To the Post‘s credit, the aritlce offers us this bit of reality:

Experience, however, suggests that treating heart attacks is very unlikely to get cheaper in the future — either for individual patients or for the country as a whole.  “The low-hanging fruit has been largely consumed,” said C. Michael Gibson, a cardiologist and chief of clinical research at Beth Israel Deaconess Medical Center in Boston. “We are now facing the battle of a half- to one percent improvements in mortality that will come at very high cost.”