The Antidote

Counterspin for Health Care and Health News

Thursday, October 12, 2006

Nobels: A new measure of health care quality?

I'm not an economist, but living in Washington, DC, I know at least as many economists as I do lawyers. I always find it interesting to hear what economists have to say about health care.

Thanks to the Health Behavior News Service blog for pointing me today to an article in the New York Times (Oct. 5, 2006) by Tyler Cowen, professor of economics at George Mason University, on innovation as a measure of health care quality, and spinning off into other musings about health care policy. I'm tempted to post a line-by-line point-counterpoint, but I'd surely end up violating fair use guidelines. And unfortunately the article just went into the archives for which you need to pay (or get a free 14-day subscription)... so I hope you'll trust me to quote and paraphrase Cowen correctly.

Cowen starts off by reiterating what we all know by now: that health care in the United States isn't all it's cracked up to be. Fine. He immediately goes on to say that "the American health care system may be performing better than it seems at first glance," because we're leaders in innovation, as evidenced by the number of Nobel prize winners in the U.S. Beg pardon? When did the number of Nobel prizes become a measure of quality, and how it is even related to the quality of care we do receive? But OK, for the sake of argument, I'll play.

First, is the number of Nobels related to innovation? Cowen goes on to list a number of technologies, most of which appear to be unrelated to Nobel prize-winning work, and in fact, began in other countries, though they have some connection to the U.S., who are "leaders in converting new ideas into workable commercial technologies." Leaders? No evidence given, but let's move on to the next question: are they workable commercial technologies? Sure, lots of hospitals have MRI technologies, CAT scanners, mammography units, and balloon angioplasty technology. ACE inhibitors are well accepted for treating heart attack victims. "Workable commercial technologies"? What does that mean? That someone can send you a bill for using it? OK, commercial I'll accept, but the next step is to look at the relationship between innovation and quality. First you'd have to assume that the innovations become part of health care. As my regular readers know, it ain't necessarily so.

Cowen describes the huge imbalance in US spending on health research compared to that of Europe, and then says something I simply don't follow:
About 400,000 European researchers are living in the United States, usually for superior financial compensation and research facilities.

This innovation-rich environment stems from the money spent on American health care and also from the richer and more competitive American universities. The American government could use its size, or use the law, to bargain down health care prices, as many European governments have done. In the short run, this would save money but in the longer run it would cost lives.

We seem to have gone from spending on research to spending on health care. How are these related? Cowen never explains. Somehow, though, he's suddenly slamming health care price control negotiated by European government, and because "in the longer run it would cost lives." Again, I have no idea what he's talking about, and this is much too important a point to leave hanging there unsubstantiated.

Moving right along. Cowen cites recent research on the relationship between life expectancy gains and health care spending (also on the dicey side, but I'll let it slide for now) and then brings innovation back in, saying that the US looks worse than it is relative to other countries not because of innovation, which has diffused to other wealthy countries, but because of lifestyle factors such as diet and physical activity. That may be, but you can't tease those factors apart from the kind of research he cites. However,
the extra money Americans spend to treat allergy symptoms, pain, depression and discomfort contributes to personal happiness.

Thank goodness we get to spend our money on allergy drugs and antidepressants; they'll help us worry less about the fact that we have some of the worst health disparities in the developed world. Similarly,
Sick people receive more momentary comforts and also the sense that everything possible has been done. This feeling is of value to the family even when the patient does not improve. In contrast, European countries have not created comparably high expectations about the medical process. If we count "giving people what they would want, if they knew it was there" as one measure of medical value, the American system looks better.

Oh, my goodness. Is Cowen serious? Can he really think it's ok that we're paying ourselves into trillions of dollars of deficit for the illusion of being well served by health care? European countries may not have created high expectations, but they actually deliver higher quality, more equitable, and, yes, more efficient health care.

Finally, after pointing out a few more of the country's health care deficiencies, he wraps up thus:
These problems should be addressed, but it would be hasty to conclude that the United States should move closer to European health care institutions. The American health care system, high expenditures and all, is driving innovation for the entire world.

I don't know - which system would you choose?


At 4:39 PM, Anonymous Anonymous said...

Considering the most important lifesaving innovations in care have been low-tech (clean water, hand-washing), the Op-Ed seems grossly misguided.

Dave L ex-JNCI

At 12:44 PM, Anonymous Maggie Mahar said...

According to Cowen, in the U.S. "Sick people receive more momentary comforts and also the sense that everything possible has been done. This feeling is of value to the family even when the patient does not improve."

Perhaps the family takes comfort in knowing that "everything possible has been done" but futile care puts patients through unncessary pain
at a time when they most need rest and comfort. I am reminded of a study published in the Journal of the American Geriatrics Society which shows that middle-aged children are especially reluctannt to let elderly parents slip away and "want to initiate resuscitation, mechanical respiration and dialysis for their terminally ill parents--even when it was not what the parents had wished, nor what the offspring would wish for themselves."
Medical ethicist Kenneth Boyd suggests that middle-aged children push to have "everything possibe" done because "it is in middle-age when awareness of one's mortality surfaces, that the fear of death is strongest." In the years that follow, many people make their peace with their own mortality, and as a result, Boyd points out "the edlerly are no more afraid of death than people in other age groups. But in middle age, letting go of the dying parent means looking over the edge of the cliff, "Losing the ambiguous parental buffer which lies (sometimes literally) between death and themselves."
See Kenneth Boyd, "Old Age: Soemting to Look Forward To?" in The Goals of Medicine: The Forgotten Issues in Health Care Reform, 156-9. For the study see M. Sonnenblick et. a., "Dissociation Between the Wish of Terminbally Ill Parents and Decisions By Their Offspring,"Journal of the American Geriatric Society, 41 (1993).


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