Science should guide health decisions

This blog post first appeared as an Op/Ed column in the Houston Chronicle.

We all know the drill: The US spends significantly more on health care than all other countries in the world and yet we have poorer health outcomes than almost all industrialized nations. Some contend that we shouldn’t spend 18% of GDP on health care. I agree, but not because good health isn’t worth that much, but because we aren’t getting value for our dollars. There are lots of reasons for this: our health care finance system historically has rewarded quantity over quality; we lack the motivation to make better decisions about the care we obtain because we do not feel connected to the cost of care; and we spend money on the wrong things. When we get the chance to change some of this, we should jump at the chance, but that doesn’t always happen. 

Consider the uproar surrounding the US Preventive Services Task Force’s recommendations about mammography.  In 2009, the Task Force recommended that routine, biennial mammography for women ages 40 to 49 who are healthy, asymptomatic women, and without personal risk factors for breast cancer is not warranted. The Task Force recommended that mammography should be offered selectively to individual patients based on professional judgment and patient preferences regarding specific harms (risks associated with false positives) and benefits because there is at least moderate certainty that the net benefit is small. The Task Force issued essentially the same recommendation last month after revisiting the evidence, including more recent data.  This month, the American College of Physicians rated this recommendation as having high value based on a review of guidelines by several health and medical organizations. In 2009, many people and organizations, including those in the business of providing mammograms, rejected the evidence-based recommendation. The reaction was so intense that the rejection was written into the Affordable Care Act to ensure that all women over age 40 could get annual mammograms without co-pays. That is likely to remain in the law, despite the updated recommendation.

There are two problems with this.  First, is it appropriate for advocacy groups, some with substantial financial stakes in providing mammography, and politicians to prevail in defining clinical practice standards? Breast cancer is a devastating disease and its eradication is an important public health goal embraced by Americans, but that commitment should not override sound science. Second, because annual mammography for women age 40 and over is covered by insurance without co-pays, women are being encouraged to get this “free,” “preventive” care.  But the care is not free—if there is no co-pay, the full cost of the service is factored into the insurance premium that someone, most likely an employer, is paying. And if the woman is not at risk for breast cancer, the care is not “preventive” and may carry more harm than benefit.

I am not qualified to evaluate the evidence myself, and these points are not made to defend the Task Force’s scientific conclusions. Rather, I am concerned that we are willing to disregard data that we don’t like or agree with, with the result being that we spend unnecessary dollars on health care that may actually do more harm than good. If this is how we make health care decisions, we will keep spending more money without getting value for our dollars.