Tuesday, September 29, 2009

Three Ways to Pay Physicians

This week I find my self reminiscing.  It was 1969 when the Harvard co op was formed to provide health care for Harvard employees and the employees of Harvard affiliates.  That became the Harvard Community Health Plan (HCHP) which was considered to be among the best staff model health plans in the country.  The plan paid physicians salaries and was run by physician managers who focused on quality of care and based care on the best information from medical knowledge.  Unfortunately, the wonderful care that the Harvard physicians were giving did not give consumers what they wanted.  During that golden era, a small voice in the guise of an article in the Journal of the American Medical Association appeared (1993) found that the public preferred solo and small group practices to HMOs!  How unenlightened of the public!  A larger voice, which was the Boston area marketplace, prevented HCHP from achieving market success and the plan was forced to merge with the then, Pilgrim Health Plan to become Harvard Pilgrim.  The salaried doctors were now joined to the private doctors.  That too did not last long as Harvard Pilgrim was soon forced to spin off the physician group as Harvard Vanguard after shrinking the salaried group.  That group now survives by contracting with all health plans.  It still gives excellent care and is still loved by some and shunned by others who perceive it as clinic medicine.

Back to the Future

We now return to the present day and find that the concepts underlying the HCHP model are alive and well and now being presented as a new option.  In this week’s New England Journal of Medicine (NEJM), Dr. Arnold Relman, one of the giants of medicine and a professor at Harvard Medical School for many years, advocates for accountable care organizations, run by physicians in which the physicians are paid salaries.  In Dr. Relman’s proposed model, there is competition between groups on the basis of service and quality but only one payer with each group being paid the same by government (or some other single payer entity).  The question is whether this is the HCHP without the messiness of having to compete.  If the only competition is other salaried groups of physicians run by physicians, is that really competition?  It just seems as though we are returning to the group model plan of salaried physicians that was rejected in the marketplace, except this time we are not allowing anyone to reject it.

Value in Health Care

In a different article. also from the NEJM , Dr. Denise Cortese of the Mayo Clinic collaborates with Jeffery Korsmo, to argue for measuring the value of health care and making these value measurements widely available on the Internet.  They define value as quality divided by cost. To quote the authors, “In this equation, quality includes clinical outcomes, safety, and patient-reported satisfaction, and cost encompasses the cost of care over time.”  The authors also make a good case for moving towards value based payment to health care organizations and even physicians as well.  They also prefer paying physicians salaries however they do modify it with a value equation.  To further quote the authors (quoting the philosopher Seneca), “The philosopher Seneca said, “We most often go astray on a well trodden and much frequented road.” There is a clear path to higher-quality, more affordable health care, if we are willing to veer from the familiar route. We must define value, publicly display understandable value scores, and pay for value.”

The Three Ways

There are generally believed to be three ways to pay physicians, fee for service with is our current system, capitation which pays physicians a set fee per person they care for as an enrollee in their panel, or salary.   One can think of these options as paying doctors to do more (fee for service), paying doctors to do less (capitation) or paying doctors to leave at five o’clock (salary).  Both articles are taking on payment reform which appears to be missing from the current iterations of the health reform package and should be the most important piece of any legislation.  Systems that pay for value and that make measurement widely available to the public are the most likely to be successful.   It is less important whether those value payments are as bonuses over a salary or are a modified fee for service system.  Perhaps this is the fourth way to pay physicians and one that will combine some of the best parts of our current approach. 

Tuesday, September 22, 2009

Belaboring the Obvious

Much of medical research is exciting and important and filled with hope for curing cancer and stopping the scourge of epidemics.  Then there is the research that has to do with what, for most, seems like the obvious.  I thought about this in the context of end of life counseling when I wrote about HR 3200, the house health reform bill.  If someone is dying, isn’t it obvious that the doctor should counsel them? Does that have to be law, with specific instructions on how to counsel a dying patient with specific options proscribed by law?  But this blog posting is not about the reform issue but instead is about new articles in the scholarly medical literature.  It is just In this month’s Journal of the American Geriatrics Society the mundane and the seemingly obvious is the topic of a number of the lead articles.  Lest you think I am just mocking these dedicated researchers in geriatrics, the older I get the more these mundane issues touch me directly.  I know these studies are important and may one day (very soon) may affect me and even you.

Someone Who Is Elderly Can Become Frail

The first two articles in the September issue have to do with deciding when someone who is elderly is also frail.  These authors from UCLA define frail to describe “older adults with low functional reserve who are vulnerable to stressor experiences and at risk for adverse health outcomes”.  (whew!)  They use a formula which includes a number of tests reflecting different body systems to indicate if someone is actually frail.  The second article written by a group in Boston from Boston University and Harvard, compared two different indexes to measure frailty.  It found that both were effective although one was simpler.  Both articles are actually important as they both challenge a disease focused approach that is embedded in the way medicine is conceptualized and the way it is practiced.  An editorial in the journal by George Kuchel at the University of Connecticut points out that the specific disease in someone who is elderly is often less important that the overall health that is implied in these different definitions of “frail”.  That too is obvious in many ways but often ignored in the practice of medicine.

Sending Elderly People Home from the Hospital Requires Planning

The third article in the journal is about a team at the Johns Hopkins Medical School who came up with a “Safe STEPS” program to help the elderly transition from the hospital to home after an acute illness.  There are some very radical approaches in this such as the physician and the pharmacist collaborating and the team having a discharge meeting to make sure everything the person needs to go home has been done.  It turns out that when you do this, those patients have fewer returns to the Emergency Room and fewer readmissions.  Isn’t that surprising.  If you think this too is obvious please note that it is very unusual to see this collaboration in care.

Advance Care Directives Have to Be Individualized

The easiest thing to do to describe the fourth article is just to quote the conclusion from this group from Yale.  They conclude that patients need “customized, stage-specific interventions based on individualized assessments to improve advance care planning”.   How radical can you get?  Patients need care, especially when they are incapacitated that is unique for them!  The study makes the point that people vary in their readiness to listen, their barriers to listening and even in the potential benefits such directives can give them.  Thus they must be approached and spoken to as individuals with specific needs and desires.

The Simple is Difficult

I could continue to go on.  Other studies in this September issue of the Journal of the American Geriatrics Society include articles about pain causing functional limitation and yoga helping spine problems.  It may all sound obvious, mundane and simple but the impact these “little” items have on health and wellbeing is often immense and the difficulty of having them done often overwhelming. 

Sunday, September 20, 2009

Ethical Health Care Reform

With the publication of the Baucus proposal for health reform, we may be entering the “end game” of negotiations about a final bill.  My intent today is not to review that bill because, while I believe it is the most realistic of all proposals in play, it is unlikely to be the final agreed upon version.  Rather it seems that with its publication, we now have at least two starting points for the final push towards legislation, the Baucus bill and the House bill.  The debate has played out thus far on financial and ethical terms and there are significant ethical dilemmas to consider.   Reform of a health care system, that no matter how confusing and flawed, still gives excellent care to those in need who access the care will not be easy or straightforward.  The debate cannot, however continue to be the cartoon caricatures that each side seems compelled to present.  I believe that the ethical issues are between two positive ethical visions and not between two opposing visions, one from the devil and one from the angels (pick which is which depending on which side you are on). 

The Proposal To Kill Grandma

Obviously there is no proposal on the table to develop death panels.  However, in the White House’s own words “the President’s plan will create an independent Commission, made up of doctors and medical experts, to make recommendations to Congress each year on how to promote greater efficiency and higher quality in Medicare”.  If we follow that proposal to one potential result, it could easily include proposals to shift spending from complex cancer treatment to prenatal services.  That is certainly good and ethical.  However if you are the 80 year old who is now not getting new cancer treatment because of that shift in resources, you may not believe it is ethical towards you.  The fact is that in a classic article written in 1995, it was found that the United States statistics on survival at age 80 is the highest in the world.  Part of the reason for that is that we, in the United States have far better survival rates for cancer than anywhere else in the world including other western democracies.  We do exceptionally well in finding people with breast and prostate cancers and treating them aggressively.  That, according to statistics from the American Cancer Society.  Would that change under some of the proposals being considered?  It could.

The Un-American Racist Proposals

On the other hand, the opponents of the Presidents plan are not liars, un-American or racist on the basis of their opposition to the reform proposals.  They are honestly worried about the high financial burden to be placed and the loss of ready access to high tech, costly care if you have a cancer or other catastrophic illness.  However they also cannot just ignore the findings as outlined by the Institute of Medicine that people without insurance are less likely to get adequate care for stroke, cancer, heart disease and diabetes among other conditions. 

The Greater Good or the Individual Good

As a nation of people who believe strongly in the Horatio Alger story that stresses individual initiative and individual responsibilities and rewards, we tend to lean towards programs and policies that allows for unique decisions in health care which includes the right to get whatever care they and their doctor believe to be appropriate for their individual predicament.  The greater good, from both a population health and a financial health point of view may involve limiting that individual decision making to some extent.  Many of the proposals currently on the table can take us down that path.  That is either a reason for celebration or a reason for caution.  Does the ethics support allowing that person to get the care that they and their physician deem to give them the best chance of life, even if the odds are low, or does the ethics support a process to determine on a population basis that, if the odds are low, the resources should be spent elsewhere.  The answer will require balance and careful discussion, not demonizing the opposition.

Thursday, September 17, 2009

Lowering Health Care Costs: The Answer

The elephant in the room of the health care reform debate is how to add 30 million people to the health insurance roles while also decreasing health care costs.  The best way to start this discussion is to state the obvious which is that health care costs are a product of the unit price of a service or product (such as an office visit, a surgery, a medication or a splint for an injury) multiplied by the number of services.  We already know that with an additional 30 million people joining the health insurance roles, that the volume of services will have to increase.  We also know that the current proposals on the table do not address unit costs.  While proposals have been put on the table to change the government formulas for calculating provider payments, they have not been included in the current versions of health reform now being proposed.  In testimony to Congress on September 15, 2009, Dr. J. James Rohack, President of the AMA stated, “We are pleased that the new target growth rates proposed in the House legislation are not limited to GDP growth”  In other words unit price will not, by these proposed statues, be controlled.  So if we can’t or won’t limit volume of services and we can’t or won’t limit the unit costs, what can we do to lower total costs?  The esteemed journal Health Affairs recently took this on with their Sept/October issue entitled “Bending the Cost Curve”.  The articles in the issue, and also the academic discussions usually revolve around three foci of cost control strategies. 

It’s the Price Stupid! 

One particular article, written by Jonathan  Oberlander and Joseph White in the Health Affairs issue make the strong case that our unit costs are just too high.  They use data comparing the volume of services in other countries that have much lower costs and find little difference with the volume of services in the United States.  They go on to show that our costly payments to physician specialists and for high tech and invasive procedures are the main contributors to high health care costs.  In a separate article in the same issue, Bruce Vladeck and Thomas Rice state that these high unit costs are due to a “lack of power on the purchasing side” meaning that insurance companies and government are virtually helpless to negotiate with physicians and hospitals as the providers of care have a monopoly of sorts and there is no cost sensitivity to their services.  They suggest that only a monopsony which is a situation in which there is a single purchaser of a particular service in a market (great SAT word for my fifteen year old) can solve this and the best monopsony to fight their monopoly is a single payer system.  Of course I do question why this tough negotiating cannot go on now as Medicare and Medicaid pay one third of all health care in the United States. 

Lower the Volume!

While the articles I have just cited minimize the effects of efforts to lower the utilization of services in favor lowering unit costs, other articles do acknowledge that lowering the “waste” in the system can lower costs while potentially improving quality. In an article by Arnold Milstein and Elizabeth Gilbertson, they cite studies by the Institute of Medicine and the Congressional Budget Office that show, “30–40 percent of US health spending is waste which primarily encompass services of no discernable value (the CBO’s focus) and the inefficient production of valuable services (the IOM’s focus)”.  In their article and in other articles in that issue, specific programs that have successfully lowered the volume of services (and by so doing lowered costs) by focusing on eliminating services with little to no value, are highlighted. 

Blame the Patients!

The third focus targets consumer or patient issues that are largely driven by culture in America.  Although that is addressed only peripherally in Health Affairs, other authors have written extensively on social and cultural influencers having major impact on costs including direct to consumer advertising for prescription medications and celebrity activities and endorsements.  It is often said that Al Roker’s obesity surgery led to a plethora of such obesity surgeries, many of which were unnecessary and inappropriate.    A classic book on this topic, Medicine and Culture written by Lynn Payer remains an excellent review of this topic.  Ms. Payer goes into great detail on the American culture being one that values technology and aggressive interventions and our health systems and payment systems reflect that cultural bias.

My Answer

In many ways my answer is the obvious one.  There is no easy answer.  There are important bits of wisdom in all of these articles yet none of them give us a simple roadmap of how to save money while maintaining or even improving the quality of care.  We will need to change the culture to some extent.  We will need to develop new payment systems to lower unit prices and we need to encourage programs such as the ones in Health Affairs that are shown to work to eliminate utilization of services that provide no value in final outcome to patients.  Only by a combined approach are we likely to have success.  Unfortunately, I do not see any reform bill that thoughtfully does all this. 

Saturday, September 12, 2009

Three Speeches on Health Reform

I admit that I did not listen to President’s Obama speech before Congress. I wanted to be able to understand his proposal and his arguments without the pomp, circumstance, standing ovations and partisan spins that are integral to such occasions. Instead I waited a couple of days and then sat down to read the text of the speech. To my surprise, I actually say three different speeches incorporated into one speaking session. They were intertwined so it may not have been readily apparent. This is, however, what I saw as I read the speech and confirmed when I read the President’s proposal on the White House web site.

Speech Number 1: The Problem and the Proposal

A major part of the speech was a recitation of the problems that are necessitating action. The fear of bankruptcy for those with catastrophic illness, the problem of being denied coverage for pre-existing conditions, the challenge for those without insurance were all outlined with skill and passion. The President’s high level proposal was largely agreeable to a cross section of Congress and the American people. The president stated, “And there is agreement in this chamber on about 80 percent of what needs to be done.” There is a large part of the President’s proposal which is seen in both Republicans and Democrat proposals. We could pass a law tomorrow if the President and Congress would just take that 80% and pass the legislation and we would have improved the system appreciably with a relatively simple agreement that eliminates pre-existing condition clauses, guarantees insurability and eliminates some of the insurance rules that create barriers to care. Even the insurance carriers support that because they will still have the level playing field and will potentially have more customers. On the White House web site, the President’s proposal is now posted and spells out some of those “significant details” that the President alluded to in the speech that are part of the 20% of which differences remain. Thus he clearly states in the White House proposal “Offers a public health insurance option to provide the uninsured who can’t find affordable coverage with a real choice”. There is little agreement on that public option which seems like it will be modeled on Medicare. Medicare which is now extremely costly to taxpayers, inefficient and largely unpopular with physicians as the payments tend to be lower than they receive from negotiated contracts with private insurers. This is the same Medicare which now offers “waste and inefficiency” which we can somehow mine for the money to pay for the proposal, but more on that in a moment. While there is little sympathy among the public for physician incomes, the fact is that we are not, as a society, able to increase the number of primary care physicians in the United States partly because the Medicare fee schedules for those health professionals falls far short of where they should be.

Speech Number 2: Demonizing the Opposition and the Insurance Companies

President Obama, intermixed his definition of the problems and his solution with a strong targeting of those who disagree with him and with the insurance companies. “Instead of honest debate, we've seen scare tactics. Some have dug into unyielding ideological camps that offer no hope of compromise. Too many have used this as an opportunity to score short-term political points, even if it robs the country of our opportunity to solve a long-term challenge. And out of this blizzard of charges and counter-charges, confusion has reigned.” Actually I have seen a lot of honest debate which the President has chosen to call scare tactics. In a wonderful column in the New York Times, Max Blumenthal quoted Eisenhower as saying, “In a democracy, debate is the breath of life.” We have seen a lot of debate and I still hope that the debate continues. In the end, it will result in a better law being passed. Yet the demonization of those who disagree is troubling. Unfortunately that demonization is strongly emanating from the While House and the Congress.

Speech Number 3: Show Me the Money

The third speech was how to pay for it. I must admit that I did not follow this very well and each time I re-read it, I still don’t understand. It seems like the centerpiece is an independent panel of physicians to suggest ways to eliminate waste and inefficiency. The nature of medical care is very personal and it has always been difficult to lower costs through the simple elimination of waste and inefficiency as one man’s waste is another’s necessity. While I know better than most of the the waste in the system as I have dedicated my professional life to finding ways to decrease cost, improve access and improve care, I also know that having a panel of independent physicians will solve nothing and will not make money appear magically. Covering 30 million people who are now not covered is not free and is not paid for by finding waste. Without comprehensive payment reform of the type that is not seen in any bill, we will just be working around the margins. In a previous blog I discussed the fragmented way physicians are paid and pointed out that the fragmentation leads to higher costs. There is nothing in the proposal to change our payment systems. An Article by Fuchs written back in May (which seems like a lifetime ago in this debate) states “A government insurance company is no substitute for real reform” yet that, and a physician panel, appears to be the drivers of lower costs in this speech and proposal. Forgive me if that just makes no sense to me.

What Happens Next

I do believe that a bill will be passed and that we will be moving into uncharted waters. I only hope it doesn’t cause more harm than good. None of us can know for sure how this will evolve and where we will go. In a future blog, I will discuss my thoughts on lowering costs and improving access while improving care.

Wednesday, September 9, 2009

Association versus Causality

I find it fascinating to read reports in the newspapers of new advances in medicine and new insights into medical care.  I try to find the hidden, or not so hidden, mistakes or misinterpretations that often occur.  In a previous blog, I wrote about reports of basic research that are years away from practical use that give the impression that therapies are immediately changing in response to the research.  Today I get to discuss another common error.  Proving an association between two different illnesses or conditions and implying that there is a causal relationship that can impact treatment when one may or may not exist. Let’s get specific:

Depression and Heart Disease

It has been known for many years that people who are depressed are more likely to get heart attacks.  In a study this past week in the Archives of General Psychiatry, it was shown that people who have already had a heart attack, have a doubling of mortality after the heart attack if they have major depression.  This article was the basis of a news article in the Wall Street Journal which asked the right question in its title “Will Depression Treat Heart Disease?”  Based on the results of this study, should the medical profession be more aggressive in treating people for depression after heart attacks?  Should cardiologists and others who treat these patients be trained in screening people after heart attacks for depression and treating them with appropriate medications and therapies?  What about the risks of using those medications on people after heart attacks?  There are risks especially in people who are known to have heart disease.  It almost seems obvious that if people with depression after heart attack have a double risk of dying, that we should be as aggressive as possible in identifying and treating depression in people with heart disease.  However it may not be as obvious as seems.

Does Depression Cause Death in Heart Disease or Does Bad Heart Disease Make You Depressed (or neither) 

That is the major real question here.  We know from the study that I cited that there is an association between heart attacks, depression and death but we don’t know whether one causes the other and which causes which.  Two recent editorials in the Sept 1 issue of the Journal of the American College of Cardiology commented on this.  One article pointed out that there was no evidence that screening for depression actually improved the outcomes of coronary heart disease.  The other, while agreeing with that fact took the position that identifying depression was good in anyone so it should be done.  While we know that depression, heart disease and death are associated, we don’t really know how best to use that knowledge to help people.  We don’t know if the heart disease is causing the depression in which case treating the heart disease more successfully might improve the depression, or if the depression is worsening the heart disease in which case we would want to identify and treat the depression in order to improve the heart disease.  Of course the increased mortality with depression may just be due to the fact that the depressed people are not taking their medications and doing their cardiac rehabilitation.  Maybe all we need to do is improve the way we give medications and encourage people to exercise and not deal directly with the depression at all.

Have I Confused You Yet?

In some ways I hope so.  Not because I want to frustrate all of you but because I do hope to show you that even an easy straightforward association may not imply a straightforward therapeutic direction.  We all want simple answers however even when the facts are simple, the answers they imply may not be. 

Sunday, September 6, 2009

Various “Factoids” from Medical Journals

Those of you who have read my blog and who have read other past efforts I have made to make medicine understandable know that I tend to follow three themes in these writings.  One is understanding health policy and the impact health care has on economics and policy, the second is bringing understanding of the care function of health that must be delivered hand in hand with the scientific aspect and lastly reporting on the new science which is published on an almost daily basis.  Ultimately, these three aspects must come together in a caring health care system that is based on sound science and is supported by valid economics.  In this posting I want to focus on a few of the scientific studies that were discussed in recent medical journals.

Personalized Genomic Medicine

In a recent blog I wrote about some of the controversies in the use of personalized genomic medicine.  In this week’s New England Journal of Medicine, there are two articles and an editorial about the selection of the right chemotherapy based on the presences of a gene.  The studies and the editorial point out that, at least in cancer treatment, the promise of using a person’s genetic makeup is a powerful way of guiding the best therapy.  Whatever controversy does exist about other uses, and potential misuses of genetic testing and analysis, it is clear that research such as this is guiding the way for using personal genomics in medical care.

Chronic Lyme Disease

There are certain diseases in our society that gain popularity as they seem to explain the problems of people with vague symptoms that no other diagnosis seems to explain.  Since Lyme disease is a multisystem inflammatory disease that can potentially cause many symptoms, there are those who believe they have this disease when they have diffuse aches and pains and fatigue.  In a study in the American Journal of Medicine, the researchers recruited 240 patients from an area that is endemic for Lyme disease.  Each of these people believed or were told by local doctors that they had chronic Lyme disease.  Less than 20% of these people had any evidence of any sort of Lyme disease either in the present or past (and standard medicine does not recognize chronic Lyme disease as a disease) however most did have a different medical illness or what is now called Chronic Multisystem Disease (meaning they hurt all over and we don’t know why).  Depression and anxiety were very common as were other personality defects.  The authors summarize by saying “multidisciplinary treatment addressing the physical and often emotional suffering of such patients will be more effective than perpetuating the diagnosis of “chronic Lyme disease”.  In my words, we often overemphasize a diagnosis when appropriate care in the absence of a firm diagnosis is really indicated.

Retail Clinics and Cost and Quality of Care

In the Sept 1 issue of the Annals of Internal Medicine, a study was described that looked at the quality and cost of care in retail clinics of the type found in pharmacies for three simple illnesses, pharyngitis (a sore throat), urinary track infection and otitis media (ear ache), compared to the cost and quality in physician offices, urgent care centers and emergency rooms.  Overall the cost of care was 30-40% lower in the retail clinics than in urgent care centers and physician offices and 80% lower than in emergency rooms.  The quality was care in the retail clinics was just as good as in the other settings.  The lower costs were due to lower unit costs since the retail clinics are usually staffed by nurse clinicians rather than doctors, and due to less lab tests being done.  Before we get too enthusiastic about this, this was a study of the costs for a comparable visits, not a study of total costs from the illnesses.  Since most sore throats just get better on their own as do some ear aches, the question is whether people who would have stayed home and just waited to get better went to a retail clinic instead, raising the total number of people being served and thus raising the total costs.  That is not known from this study.  But it does show that these retail clinics fulfill their promise of lower costs and high quality.

Wednesday, September 2, 2009

Modern Medical Myths

Medicine can be magical, filled with articles of faith and hope rather than science and rationality.  There are those who believe that this aspect of medicine left when the day of the witch doctor and the shaman was overtaken by the wisdom of science and the white coats that represent the modern health professional.  I submit that we still hold on to myths, even within the erudite discussions taking place in the press and in the public square as we debate health care reform.  Our myths have changed but they are no less powerful than the ideas that led to the bleeding of evil humors in order to cure disease. Let’s review some:

Most Illnesses are Preventable and Focus on Prevention will Save Money

It is true that many diseases are affected by our life style choices.  We eat too much, exercise too little and drink too much alcohol.  That all leads to disease which could be avoided if we all practiced moderation.  The myth is created by the idea that focus can greatly impact risk reduction to the extent that billions of dollars will be saved and the suggestion that people can modify their lifestyles successfully and prevent disease on a national scale.   The facts differ somewhat from this dogma.  Dee Edington and his team at the University of Michigan have been doing research in this area for more than thirty years.  In a recent, 2009 article in the Journal of Occupational and Environmental Medicine they looked at a large population that they had followed for eight years, assessing them yearly through questionnaires (health risk assessments) and providing multi-dimensional health risk reduction programs.  Their findings were that any positive change in reducing risks was minimal.  In that April 2009 article they stated: “No argument exists against the relationship between higher risk and higher health care cost, but optimal strategies for facilitating and sustaining changes are still elusive.”  Dr. Edington has told me personally many times that the real goal of health risk reduction should be to try and keep people from increasing their risks rather than try and get the true reversal of risks as that true reversal has thus far not been possible for large groups of people. 

All Diseases That Are Discovered Early Can Be Treated To Cure

If this were only true!  We know that early detection of hypertension allows for treatment and can help prevent certain types of heart disease and that early detection of some cancers allows a better likelihood of cure but the needed research has to be done on a disease by disease basis and may not hold true.  Prostate cancer, and the use of a Prostate Specific Antigen (PSA) blood test to try and screen for that cancer are an example of screening that may not help people survive.  In the words of the  American Urological Association Best Practice Committee on PSA, “at this point it is not possible to state that screening is associated with more benefit than harm”.  Every positive screening test for any cancer will cause more tests and procedures to be performed.  All of these diagnostics carry their own risk and we often do not know if that one case found may be causing more than one person to end up with a life threatening complication of an unnecessary procedure.  Even when we do find a cancer early, there is no guarantee that we can effectively treat it at that point.

The Ultimate Myth: Death is Optional

There is an old saying that life is a fatal disease.  In our society we often don’t act that way. We tend to want to find answers that tell us that death and illness are always avoidable.  That is not the case.  We fight disease and we prolong life and we try to do it in a way that celebrates the triumph of life and that never loses hope. We can do that without fooling ourselves with myths.

Myths and Health Reform

All of this comes to mind as we discuss massive reform in our health insurance systems.  My advice is to be skeptical of claims that we will save money by decreasing health risks in the population.  Question the dogma that earlier detection of disease will inevitably lead to more cures at lower costs.  Medicine is much more complicated than that and health reform is still just a piece of legislation and will not change human physiology and human behavior.