I just read a note on the Health Care blog by Dr. Lundberg a highly respected physician. He makes several proposals to reduce health care costs.
He suggests:
"1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually....2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually."
Yes it would save billions but at what human cost. He is suggesting pharmaceutical treatment rather than surgical. However with 90% blockage or more there is no evidence that drugs will do anything. This is strange since the body of medical evidence is overwhelming that surgery and stents do have beneficial results. The question is the classic $/QALY result but even there we have a positive result.
He continues:
"3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here....4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved."
Yikes is the best I can say. The evidence on breast cancer is overwhelming as well. Just search either JAMA or NEJM and you need go no deeper into the specialty journals. There is the prostate cancer debate which really is a debate on the genetic makeup of the specific type of prostate cancer. Watchful waiting works on those indolent forms but regrettably we do not have adequate genetic markers readily available. In fact PSA screening is a great way to accumulate the data.
He continues:
"5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved...6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved."
Yes on the imaging he may have a point. In the old days the physician could determine what ligament was at fault by just examining the motion of the limb and at the other extreme one could do an untra sound on an ovary before the MRI and CAT of the abdomen. However to distinguish between a block or bleed stroke there is no other way, you need a CAT. As to chemotherapy, take taxol and breast cancer, it does work, take the childhood leukemias, they are cured now whereas thirty years ago the child died. So I am amazed as to this out of hand dismissal of chemotherapy. Yes it is problematic with many cancers, such as melanoma, but there is clinical evidence of where it works and where it does not.
Finally he says:
"7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false
hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved."
One could not agree more. The classic phrase spoken by a dying patient is something like, "It's time to go now..." and the patient all too often knows that the end is near. Managing pain, managing and respecting dignity, they are all critical. The past blog on advance care planning speaks to that issue. Yet as we have stated there the issue is all too often a cultural and family issue, less the patient qua patient.
Dr. Lundberg is so respected a physician and is such a figure of prominence in the Medical profession that it is a question why he made these remarks. As one would typically ask, what is the basis for your statement, and also at what cost; human and financial?
He suggests:
"1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually....2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually."
Yes it would save billions but at what human cost. He is suggesting pharmaceutical treatment rather than surgical. However with 90% blockage or more there is no evidence that drugs will do anything. This is strange since the body of medical evidence is overwhelming that surgery and stents do have beneficial results. The question is the classic $/QALY result but even there we have a positive result.
He continues:
"3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here....4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved."
Yikes is the best I can say. The evidence on breast cancer is overwhelming as well. Just search either JAMA or NEJM and you need go no deeper into the specialty journals. There is the prostate cancer debate which really is a debate on the genetic makeup of the specific type of prostate cancer. Watchful waiting works on those indolent forms but regrettably we do not have adequate genetic markers readily available. In fact PSA screening is a great way to accumulate the data.
He continues:
"5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved...6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved."
Yes on the imaging he may have a point. In the old days the physician could determine what ligament was at fault by just examining the motion of the limb and at the other extreme one could do an untra sound on an ovary before the MRI and CAT of the abdomen. However to distinguish between a block or bleed stroke there is no other way, you need a CAT. As to chemotherapy, take taxol and breast cancer, it does work, take the childhood leukemias, they are cured now whereas thirty years ago the child died. So I am amazed as to this out of hand dismissal of chemotherapy. Yes it is problematic with many cancers, such as melanoma, but there is clinical evidence of where it works and where it does not.
Finally he says:
"7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false
hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved."
One could not agree more. The classic phrase spoken by a dying patient is something like, "It's time to go now..." and the patient all too often knows that the end is near. Managing pain, managing and respecting dignity, they are all critical. The past blog on advance care planning speaks to that issue. Yet as we have stated there the issue is all too often a cultural and family issue, less the patient qua patient.
Dr. Lundberg is so respected a physician and is such a figure of prominence in the Medical profession that it is a question why he made these remarks. As one would typically ask, what is the basis for your statement, and also at what cost; human and financial?
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