Medical Ethics and Medicare Politics

Two stories earlier this month tell a David and Goliath story about the U.S. health care system. Unfortunately, Goliath is winning.

Atul Gawande’s superb and widely cited New Yorker article “The Checklist” presents the “David” story. Intensivist Peter Pronovost has created checklists for key intensive care unit functions like managing intravenous lines and maintaining ventilator function. Implementing the checklists has produced spectacular results in preventing infection and improving survival. But despite their effectiveness, the checklists have in large measure been ignored. Gawande comments:

“If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them.”

In contrast to the humble checklist, nuclear particle accelerators that deliver proton therapy, as described in a recent New York Times article, are mega-Goliaths. They are housed in football field sized buildings, weigh more than 200 tons, and currently cost upward of $100 million. Prostate cancer has thus far been the main target for proton therapy. A support program, “Brotherhood of the Balloon” (named for the water-filled balloon inserted into the rectum at the time of treatment) maintains a well designed informational website. Sites that offer proton therapy – like Loma Linda in Southern California, advertise widely and effectively.

Proton therapy appears to be comparable in effectiveness to alternative treatments – surgery and radiation. Not surprisingly, given its complexity, it is substantially more expensive. Although a cost-effectiveness study published four months ago concluded that proton therapy is not cost effective for most men with prostate cancer, 16 treatment centers are under development.

The checklist project costs relatively little and achieves substantial results. Proton therapy costs a lot and achieves substantially less per dollar invested. But in a health system that worships technology and avoids using cost effectiveness considerations, Goliath wins hands down.

Proton therapy is not a bad thing. But its energetic dissemination, compared to the lackluster uptake of checklists, tells a lot about why our health system costs are out of control and outcomes are mediocre relative to expenditures. Our reward systems favor Goliath. Proton therapy is glamorous and pays well. Checklists are humdrum and pay poorly.

Wringing our hands about misguided values will accomplish nothing. Controlling health costs requires structural changes. Medicare, which calls the tune for health insurance, is currently not allowed to consider cost effectiveness. Allowing Medicare to use its purchasing power wisely will require political action. Until this occurs Goliath will continue to prevail.

(P.S. Readers may have noticed Gawande's Op Ed about the checklist project and a misguided requirement for informed consent in today's New York Times. I will write about that topic tomorrow.)