There are a number of treatments for early-stage, slow-growth prostate cancer. These treatments range from “watchful waiting” — not treating the cancer at all, but just keeping an eye on it — to surgical removal of the prostate gland, to high-tech proton radiation therapy using a proton accelerator. The costs for the various treatments range from a few thousand dollars to hundreds of thousands of dollars.
However, there is little evidence that the more expensive treatments are any more effective than the cheap ones, including watchful waiting. Indeed, for an older patient, watchful waiting makes sense, as there is a high probability he will die of other natural causes before the prostate cancer becomes a problem for him. On the other hand, younger patients, meaning men under the age of 65, might benefit from more aggressive treatment. But which more aggressive treatment?
At the New York Times, David Leonhardt interviews some prostate cancer specialists and finds there is widespread skepticism that the new, expensive, state-of-the-art treatments work any better than older, less expensive treatments.
“No therapy has been shown superior to another,†an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, “We’re not sure how good any of these treatments are.†When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, “Watchful waiting.â€
Naturally, the health care industry is pushing the more expensive treatments.
And in our current fee-for-service medical system — in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients — you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.
Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data. A new proton treatment center will open Wednesday in Oklahoma City, and others are being planned in Chicago, South Florida and elsewhere. The country is paying at least several billion more dollars for prostate treatment than is medically justified — and the bill is rising rapidly.
This takes us back to the issue of private insurance companies. Or, should I say, the the medical-industrial complex, which includes private insurance companies? I’ve ranted for years that our system is very good at one thing — creating profitable health care products. Medical treatments that make somebody a lot of money somehow get paid for. But any part of the health care system that can’t be made profitable is allowed to rot.
So, there are billion-dollar investments being made to build prostate cancer proton treatment centers that may or may not be any more successful than older radiation therapies that doctors have been using for years. Or, more successful than doing nothing at all, for that matter.
Meanwhile, just as one example, the nation’s emergency rooms are crumbling into decay. Emergency rooms do not make a profit. They have very high overhead because they have to be ready for, well, emergencies. And many people who use emergency rooms can’t pay the bills. So many hospitals are closing or cutting back or downsizing emergency rooms.
(And the practice of using emergency rooms as default “free” clinics for the poor and uninsured not only adds to the burdens on emergency rooms; it is also probably the least cost-effective way anyone could think of to provide last-ditch health services to the poor and uninsured, which is another big reason our nations spends so much on health care.)
Anyway — it appears that if somebody is making money off a particular gizmo or course of treatment, the health insurance industry manages to find room in its heart to pay for it. However, the private insurance companies routinely refuse to cover people who have even minor “preexisting conditions” and drop customers whose ailments are money-losers.
Put another way, if current trends continue, the day will come when the medical-industrial complex will simply refuse to provide treatments that aren’t making a profit for some part of the medical-industrial complex. And consider that conservatives not only want to kill government-led health care reform; they want the private insurance and other parts of the health-care industry to be even more unregulated and unwatched than they are now, and the government “safety nets” to be dismantled, on the theory that the “free market” fairy will solve our problems, even though there is no place on earth in which 21st-century medical care is being delivered by a “free market” system.
Leonhardt’s interviews show us that when it comes to health care, “profitable” and “effective” do not necessarily find their way into the same ball park. Weirdly, “profitable” and “cost-effective” are not necessarily fellow-travelers, either. That’s because the medical-industrial complex does not make a profit from curing you; it makes a profit from what it call sell to you, whether it cures you or not. And if two treatments are shown by studies to be equally effective, the industry will push the one that provides the higher profit.
Let’s go back to our gentlemen with early-stage prostate cancer. “You have cancer” has got to be among the worst pieces of news anyone ever gets. “You have cancer, but let’s not treat it” doesn’t sound much better, and I understand why some patients would push their doctors into providing some kind of treatment. Leonhardt says a Swedish study on treatment effectiveness recommends removal of the prostate gland for men under age 65. Such surgery can result in sexual dysfunction, however, so I understand why men may want another option. So doctors say, well, there is this new proton-therapy treatment …
One of the reasons the medical-industrial complex gets away with scamming us is that doctors themselves often do not know which treatment is most effective. There is remarkably little effectiveness testing going on. “Drug and device makers have no reason to finance such trials, because insurers now pay for expensive treatments even if they aren’t more effective,” Leonhardt writes. So the doctors often have little else to go on but what the sales reps tell them. And some doctors are as keen to boost their revenue streams as anyone else in the complex.
A critical part of President Obama’s health care proposal is called “comparative effectiveness research (CER).†CER is not, as the Right claims, a plan that would allow the government to countermand a doctor’s decisions based on cost-effectiveness studies. The common claim on the Right that CER is about rationing is a lie. The point behind CER is to fund the kind of effectiveness testing that is not being done now and provide that information to doctors and patients, so that doctors and patients can make more informed decisions about what course of treatment to pursue. (See also what Dr. Howard Dean says about CER.)
Of course, if CER becomes government policy, all those billions of dollars being invested to build proton accelerators to treat prostate cancer might not bring much of a return, which brings me to my last point.
Whenever I publish something about health care I get comments claiming that the private, for-profit health care industry is always better than “the government,” all we need is tort reform, blah blah blah, or that government (as opposed to the health insurance industry?) shouldn’t be involved in health care decisions. I agree with the latter; the government shouldn’t be involved in health care decisions, but nobody is saying otherwise.
The mendacious anti-reform talking points repeated ad nauseam by the dittoheads of the Right are generated by a network of right-wing think tanks and other organizations that exist solely to influence public opinion. This network is very good at getting their propaganda uncritically parroted throughout mass media and the Internet, repeated over and over until it becomes “common knowledge.” And in many cases the deep pockets funding those think tanks are also heavily invested in the medical-industrial complex. And round and round it goes …
