Wednesday, July 22, 2009

Cadillac or Prius healthcare?

Reuters' Maggie Fox has filed a report today called "No 'Cadillacs' in US healthcare reform proposals". She gives an example of a BCBS plan that is considered by most a "Cadillac" of healthcare coverage, but, alas, upon closer scrutiny leaves many gaps in the high-end disease coverage. She also describes the familiar rhetoric employed by the American Cancer Society's Cancer Action Network, the political action arm of the ACS. ACSCAN President Daniel Smith is quoted as saying that "too many cancer patients are delaying or forgoing lifesaving screenings and treatments because of access problems". This is interesting use of the word "access". We are used to equating coverage with access, but in this case the CAN statement refers to coverage limits set by the insurer, and advocates for swift healthcare reform to remedy this.

But should the intent of healthcare reform be to bring us closer to "Cadillac" coverage? I do not think so: we need to aim for the efficiency of a Prius. The amount of unnecessary and even harmful interventions is staggering and increasing every day. Because currently healthcare is a business that relies on traditional market forces, its implicit purpose is to generate revenue. And while there is tension between purveyors of gadgets and procedures and the payor, a critical approach to coverage is viewed with suspicion by the consumer. Take, for example, screening mammography for low-risk women between the ages of 40 and 50 years: although experts admit that there is little evidence for its value, it is political suicide for the payor not to cover it. The PSA story is similar, as is cholesterol screening, and many other tests and treatments we undertake with blind acceptance.

So, if Mr. Smith is truly worried about access, he and his organization need to take a step back and support evidence-based, rather than politics-based, decision making in healthcare. Universal access should never mean that all of us can get every test or treatment on the market, no matter how marginally effective or ineffective it is. Universal access means using critical thinking to make rational choices.

Bioethicists' litmus test for recognizing rationing is the question "would you do it if it were free?" I would guess that if all of us were well informed about the seamy side of doing "everything", we would refuse many an "evidence-based" recommendation that medicalizes our lives in favor of healthy and happy living. The result? Fewer worried well, less preoccupation with transient ailments, and yes, a lower overall healthcare bill with money left over to cover everyone for what they truly need. And, Maggie, Cadillacs are so 20th century!


  1. Variations on this seem to be in the air today. A couple of interesting items around the issue of Evidence-based policy vs the virtues/benefits of simpler DSS

    Now, as you might imagine, my sympathies lie with the advantages of evidence-based policy but we will always trip over the issue of what some people consider to be acceptable evidence. Plus, it would always be unwise to overlook Gigerenzer's support for 'fast and frugal' decision making.

    However, there may be an argument for evidence-based policy and guidelines that still leave enough freedom for personal/professional judgment (the 'fast and frugal' approach, as it were).

  2. Thank you for your thoughtful comment, Evidence! I agree with you that we cannot get into analysis paralysis in decisive situations. Why, even Sackett's original EBM definition left room for experience and judgment. However, this may work in the Anglo-Canadian system, where no incentives to overuse exist, but here in the US of A, where Market is king, we know from the Dartmouth guys and from Gawande's recent sojourn that our judgment is not always impartial. Andwe do not even have to invoke overt evil intentions: remember Arendt's "Banality of Evil"? It is easy to justify this behavior as normal when on the one hand you are squeezed and on the other everybody is doing it.

    Thanks for the links as well. I do have to disagree with Professor Shepherd's assertion that "hospitals routinely abandon ineffective treatments" -- we know that that is not the case here, and, in part this is a driver of our rapidly escalating costs and poor quality healthcare.