"Misplaced Priorities"

If you haven't seen all the entries in the discussion over at The American Prospect website on health care reform, I invite you to do so by clicking here. Most of the respondents to Ezra Klein's original essay (me included) agreed that controlling costs will be crucial to passing meaningful reform, since a public that already spends 16 percent of GDP on health will reasonably look askance at spending even more to cover the uninsured.

My call for prevention medicine as cost-effective medicine was echoed in more authoritative terms in an essay in the
Journal of the American Medical Association by Steven H. Woolf, a physician at Virginia Commonwealth University.

I believe the public interest is served by making this essay widely available. You can read it by clicking on . . .

Excerpts reprinted without permission from the Journal of the American Medical Association.

Potential Health and Economic Consequences of Misplaced Priorities

. . . The "silo" mentality that pervades so much of clinical practice and policy in the United States often finds decision makers focusing their attention and resources on a specific patient or disease—any one is a worthy cause—without stepping back to examine the balance of their efforts. Most practitioners and policy makers rarely pause to consider whether more rational priorities would offer better outcomes for their patients.

Lacking this "big-picture" perspective, many choices in clinical practice, policy, and research end up concentrating resources on interventions that do less for health while shortchanging alternatives that would save more lives. Reordering priorities to maximize health benefits is essential not only on moral grounds—to lessen disease burden on the public—but also as a necessary countermeasure to increasing health care costs. To illustrate the importance of reordering priorities, this Commentary presents examples from 4 areas of practice and policy: choosing effective services, delivering care, preventing disease, and fostering social change.

Choosing Effective Services

The United States spends more on health care—16% of its gross domestic product—than does any other country, yet its health outcomes are below average on major indices. One reason for the enormous health budget—$2.0 trillion in 20051—is that society overspends on unnecessary tests and treatments, many of which lack evidence of effectiveness and some of which induce net harm.

While the nation spends profligately on such services (overuse), it fails to deliver effective services that do improve health (underuse). Patients receive only 55% of recommended health services, and disadvantaged patients and minorities fare worse. Giving greater priority to effective care while curtailing overuse of ineffective services would enhance outcomes and has been advocated for years, but the imbalance persists. Practice conditions encourage overuse, such as advertising campaigns that promote marginally effective drugs, lucrative reimbursements for procedures, and medicolegal liability for physicians who withhold these therapies. These circumstances fuel spending, consuming resources that would provide greater health gains and reduced mortality if redirected to effective care.

The most effective interventions to achieve the main goal of medicine—to help patients live longer in good health—do not always receive commensurate priority in practice. The magnitude of differences in the effectiveness of available options is often unrecognized. For example, regularly offering smoking cessation counseling would save society an estimated 1.3 million quality-adjusted life-years (QALYs), whereas improved breast cancer screening would save an estimated 91 000 QALYs (a ratio of 14:1). A health system that ignores these differences and concentrates on mammography screening with little attention to smoking cessation can expect progress in reducing breast cancer but ultimately more of its patients may die (of smoking-related diseases). The disproportion may also cost more. Paying for smoking cessation counseling yields a net savings for society, whereas breast cancer screening incurs a net cost (more than $35 000 per QALY). Both interventions should be pursued, but giving measured emphasis in proportion to benefit would optimize results in both lives and dollars.

Delivering Care

Singling out the most promising treatments rightly occupies the attention of academia and industry, but the billions of dollars spent on this endeavor obscure a potentially more effective way to save lives: improving the fidelity with which the treatments are delivered. Defects in the US health care delivery system prevent patients from receiving the interventions they need, delivered correctly, precisely when they need them. Quality and patient satisfaction in the United States are worse than in many other developed countries, such as the United Kingdom, Canada, and New Zealand. Widely recommended transformational system changes to improve access, streamline care, improve communication, and reduce errors are progressing slowly.

Amid these conditions, society invests heavily in medical advances (eg, breakthrough drugs and technologies), but such advances hold little promise for improving health if patients cannot receive them. It is therefore important to consider how the United States should balance its investments in (1) biomedical advances and (2) building a system that can deliver those advances reliably. A logical approach would be to allocate resources for the 2 in proportion to the relative good that each provides. Breakthrough treatments, delivered poorly, could save fewer lives than improving the delivery of established therapies. According to one analysis, more strokes could have been prevented in the last decade by ensuring that all eligible patients took aspirin than by developing more potent antiplatelet drugs.

It follows that the United States should focus as many or more resources on restoring quality as on biomedical advances, but reverse priorities prevail. In 2006, Congress allocated $28 billion to the National Institutes of Health, mostly for research on basic science and new treatments. In the same year, however, Congress allocated only $319 million to the Agency for Healthcare Research and Quality. That is, for every dollar spent on developing treatments, one penny was spent to ensure that patients actually receive them. The blueprint for translational research—the "bench-to-bedside" progression from basic science to new treatments—gives little attention to the question of how those treatments will reach patients.

Preventing Disease

Few crises are easier to predict than the impending surge in chronic illnesses. The ingredients for the crisis are clear: an aging population, longer life spans in which chronic diseases can progress, and increasing costs to care for those illnesses. The inevitable outcome—a large population of seniors with costly chronic diseases—threatens the solvency of the Medicare program and the capacity of hospitals and clinicians to provide effective care.

This climate makes the logic of prevention difficult to ignore. Most major chronic diseases are amenable to prevention because their causes are generally known. It is estimated that 38% of US deaths are attributable to 4 behaviors: smoking, poor diet, physical inactivity, and alcohol use. Weight loss and exercise can curb the progression of diabetes by 50%. By stemming the increase in chronic diseases, prevention can reduce costs for employers and payers and contribute to a healthier workforce. The logic of prevention has always been compelling, but the obesity epidemic makes it paramount. The burden of disease that obesity could inflict on the next generation could overwhelm the capacity of the health care system.

Evidence supports the intuitive notion that the prevention of disease is more effective than treating its complications. In an analysis of 7 studies of the decline in heart disease mortality between 1970 and 2000, reducing risk factors (eg, smoking, lipids) had greater influence (by a median ratio of 1.3:1) than medical care. Tobacco use alone accounts for 430 000 US deaths each year, whereas full delivery of some cardiovascular treatments (eg, -blockers, warfarin) would each avert no more than 17 000 US deaths annually. In one British study that compared the benefits of cardiovascular treatments vs risk-factor reduction, the latter accounted for 79% of the life-years gained.

Such compelling data and the threat of chronic diseases make a strong case for society to invest decisively in prevention, perhaps more than in treatment, but reverse priorities prevail. Although precise data are lacking, estimates are that prevention accounts for only 2% to 3% of health spending. The health system concentrates resources on late-stage disease; 25% of Medicare expenditures are for care in the last year of life. Some have acted boldly to address obesity and smoking. For example, several governors have launched statewide healthy lifestyle initiatives, municipalities have banned smoking in public places, and school vendors are replacing snacks and sodas with nutritious alternatives. In general, however, society tends to underemphasize risk reduction and to tolerate conditions—eg, advertising, fast foods, workplace policies, built environments—that discourage healthful habits. The United States' propensity to spend heavily on treatment but comparatively little for prevention may imperil the nation's health and economy.

Fostering Social Change

The health of the poor and of minorities is markedly worse than for others. Income, education, race, ethnicity, and social inequality collectively exert profound influence on health. A black newborn is 2.4 times more likely than a white one to die by age 1 year (in 2003, 13.5 infant deaths per 1000 live births for blacks vs 5.7 infant deaths per 1000 live births for whites). The disparities are so large that eliminating their underlying causes could rival medicine and public health interventions as means to control disease. With all of medicine's advances, mortality rates over the past century have declined at a consistent, modest rate of 1% per year. Throughout these decades, however, age-adjusted black mortality rates have been 30% higher than those of whites (in 2003, 1066 deaths per 100 000 blacks vs 817 deaths per 100 000 whites). Closing so wide a gap has the potential to save more lives than the modest year-to-year reductions achieved incrementally by biomedical advances. By some estimates, for every life saved by such advances, 5 lives would be saved if blacks experienced the mortality rates of whites and 8 lives would be saved if adults with lesser education experienced the mortality rates of college-educated adults.

Addressing the root cause of these disparities conveys benefits beyond the health sector. Education, for example, not only promotes better health choices but also enhances job opportunities, improving earnings and access to health insurance. A more educated populace can make the workforce more competitive, strengthen the economy, lower crime rates, boost tax returns on higher earnings, and reduce welfare demands. A study that took these broader societal benefits into consideration estimated that reducing grade school class sizes would add QALYs to students' lives and generate net savings for society ($168 000 per graduate; P. A. Muennig, MD, MPH, Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY, unpublished data, January 2007). Seldom can medical advances do as much for health and society and save money.

If this is true, the US strategy to reduce disease should emphasize the alleviation of social distress at least as much as medical advances, but reverse priorities dominate government today. Budget pressures fomented by increasing health expenditures, along with political concerns, have caused the government to reduce funding for social programs, thereby undercutting an upstream strategy to curtail health spending. Social distress is worsening—severe poverty increased by 20% between 2000 and 2004—while trillions of dollars are spent on health care.

Why Disproportion Prevails

This Commentary portrays a society that invests attention and resources in disproportion to their potential to do good, permitting greater disease and deaths, which begs the question of why this occurs. One possibility is that the public and its leaders are unaware of the disproportion. They may see virtue in a good cause, such as treating cancer or diabetes, and may not realize that the same energy, redirected, could do greater good. Some leaders may sense that more effective options exist but demur because they doubt the feasibility of actionable policy.

However, there are other potential explanations. Leaders would not make choices that compromise population health and increase costs unless there were competing priorities. Shifting attention and resources to more effective options meets resistance from those who stand to lose, such as federal agencies and research laboratories that will receive less funding, specialties and facilities that will perform fewer procedures, industries that will forfeit profits, politicians who will disappoint constituents, and taxpayers who must subsidize publicly financed programs. Such tensions pit 2 prevailing ethics against each other—American individualism vs the utilitarian commitment to the common good—and the resulting deadlock has, for years, mired the status quo in place.

What now moves the issue beyond a debate in ethics, however, is the hard reality of the health care crisis. Those who would be morally content to preserve self-interests at the expense of greater disease must now confront the looming economic ramifications. As the hardship from spiraling health spending intensifies for corporate America, government, and the economy, pressure may build to eschew self-interest and deploy health dollars in ways that more wisely maximize benefit.

What It Will Take to Reorder Health Priorities

A society unaccustomed to basing priorities on population needs also lacks the infrastructure to do so. To rectify disproportion, policy makers need data to determine which options will accomplish the most good. The extensive literature on cost-effectiveness provides only a few examples in which the relative effectiveness and cost-effectiveness of all treatment options are displayed for comparison.4 Funding for this kind of inquiry is scarce. Even when congressional committees and other decision makers can access such data, their operating procedures rarely require analysis of the information, or even consideration of the big picture, before setting priorities.

Such procedures exist in other countries that apparently have stronger interests in rational allocation of resources. Leaders in Scandinavia, Britain, and elsewhere in Europe often apply evidence-based priorities,25 and they use agencies funded by government to assemble the data needed for such decisions (eg, UK National Institute for Health and Clinical Excellence, Health Evidence Network of the World Health Organization). The acceptance of rational priorities in these countries, along with other factors, may explain why they enjoy better health than in the United States despite spending less.

To reorder health care priorities in the United States will require resolve, from which the rest will follow. Health care leaders, elected officials, and the public they serve must embrace the concept that lives are lost by disproportion and should resolve to do something about it. Until the nation devotes resources to interventions in proportion to their ability to improve outcomes, its citizens will pay extra for health care—in lives and dollars.

Posted by gooznews at February 6, 2007 05:39 PM