Fidel Davila:
I just read an interesting article: "The nearly good, the bad, and the ugly in cost-effectiveness analysis of health care" by W. Hildred and L. Watkins, Journal of Economic Issues, 30(3):755-775, September 1996. There are an extraordinary number of problems with applying cost-effectiveness/cost-benefit analysis to this field and this article takes a tour of the problems. The problem with Health Care "Cost" is that in Health Care it is "Costs" -- plural not singular! (just like "cancers" not "Cancer")
A couple of years ago I delivered a talk in Washington, DC on the un-understood numbers of Health Care Costs. I defined total health care costs as:
CostsT = (DE + IE) + (HL + HPS)
DE = Direct Economic (dollars paid for health care whether diagnostic, therapeutic, preventative, etc including non-use, ie, insurance premiums)
IE = Indirect Economic (dollars loss in lost of productivity, replacement costs etc.)
HL = Loss of Human Life (with or without Health Care)
HPS = Human Pain and Suffering (with or without Health Care)
As an aside, lawyers like to turn HL and HPS into DE dollars.
Those who deal with "Cost Accounting" deal with DE only. Physicians mainly deal with HL and HPS. So as technology has decreased HL and HPS physicians are much more willing to use it, thus DE has gone up and I suspect (but alas cannot prove!) that IE has also gone down and along with lower HL and HPS CostsT have gone down. The bean counters don't know or care about IE and HL&HPS. Therefore their analyses will always be skewed and irrelevant to practicing.
BTW, since technology has decreased HL&HPS so much, the question we should be asking our selves is no longer "Can we do it?" but rather "Should we do it?" when it comes to the care delivered to our patients. In other words, when risks are zero or low (eg MRI, CT scans, etc) the benefits/risks ratio is infinite or very high. Therefore everybody should get it. Thus, instead of dealing with costs-benefits or costs-effectiveness ratios one should deal with QUALITY of care. Yet, that is another story.
Michael Bayme:
By this logic everyone who sneezes will get a ct to r/o an abscess. Sort of like Medicare in the "good old days." Costs are real, and nowadays, very public. Your argument basically says that HSF = $100 trillion (just some absurdly large #), the lawyer, congressman, etc. says human sufferring = $100 thousand.
We could poll everyone as to the dollar equivalent they'd place on HSF, but given the public pressure to reduce health care spending, the answer is going to be something less than we (physicians) expected.
David Crippen:
The concept of "quality care" and individual physicians management of it is a pleasing but very abstract one. There are several jokers in this deck waiting to rear their ugly tousled heads. Remember that you cannot talk about cost versus benefit unless you talk about supply and demand in the same breath. They are covalently bonded to each other. (Some) physicians have the illusion that they control cost versus benefit in some fashion. I think that is true only until those decisions buttress the patient's demand curve in a uncomplimentary fashion.
If you tell a patient that they don't need a chest x-ray because they have no clinical evidence of pneumonia, or they don't need an EKG because their chest discomfort in clearly not cardiac related or blah.....blah....blah......you'll probably get away with it (on a cost/benefit rationale) because the patient doesn't really know much about these things and they are willing to take your word. The "personal importance index" is low.
Telling a 40 y/o woman with advanced breast cancer that she can't have the latest whiz-bang total body transplant for a cost of two million dollars per treatment with only a 10% chance of temporary remission and a 1% chance of a cure because the cost does not justify the benefit will get you a bop on the head and a trip to the corner in a dunce hat. Telling the family of a 70 y/o victim of multiple organ system failure, failing on every life support system known to man with wide open drips that continued treatment is costly out of proportion to benefit will get you a very big bop on the head if they feel otherwise.
A very expensive and time consuming "gatekeeper" system sprung up in the early 90s to divert non emergencies from emergency rooms. I do not believe I have seen a gatekeeper divert a stupidity-related complaint in the last two years or so. They all get called and they all allow the admission no matter how stupid (and expensive ) it is. Why? Not so much from fear of lawsuits any more. The (prospective) patients pitch a fit, scream and yell, jump up and down and threaten to call everyone they can think of to complain. Therefore, the gatekeeper simply doesn't want or need the hassle. So, in addition to the negative cost/benefit ratio of inappropriate ED admissions, add the cost of a gatekeeper system that throws open the gates.
Therefore, I think that the entire concept of cost v. benefit is a practical nonentity. The availability of medical goods and services varies according to the ability of those who desire them to bully and intimidate the system into giving them up. You have little or no control over it.
Fidel Davila:
Exactly! You got the point. We can't use do everything to everyone just becasue the risks are zero making the benefits infinite. Thus the question changes from "Can it be done?" to "Should it be done?" In other words, we have to change the logic.
I ordered very few pneuomoencephalograms for normo-pressure hydrocephalous in the days prior to CT and most were positive. Due to risks, I was sure they had it prior to ordering the test leading me not to order the test in some that might have had it. But now if I suspect it I order a CT. The difference between now and then is much lower risks.
In answering the "Should be done" question Quality of Health Care comes in to play (instead of cost benefit or cost effectiveness ratios). There are four elements to Quality of Care.
I. Warranted for the specific AND general conditions involved. (i.e., Don't transfuse a decapitated person just because they are hemorrhaging)
II. Least risk to the patient
III. Cost efficient (i.e., done without wasting dollars)
IV. Leads to patient satisfaction.
As you will notice DE costs do play a role in quality of care but it is in the efficiency of dollars used. Cost containment is something society or a large organization does to limit the number of dollars spend and cost-effectiveness is deciding where from manyh options the dollars should be spent. Neither have anything to do with quality.
So, even if health care costs were zero and risks were zero, I still wouldn't order CT for everyone who sneezes. It isn't what should be done nor quality care.