Wednesday, August 6, 2008

Prostate Cancer Screening

In organizational and health system ethics, the public is a key stakeholder. I've thought for a long time that widely held public values impede our ability to get a grip on health care costs. So the question of how public values change is a big one for me.

The best opportunity for our coming to see health care cost containment as an ethical responsibility - not a moral abomination - will come from a combination of perceived crisis and effective leadership. As I've written (most recently here), the looming crisis is Medicare going broke. We're seeing that a $1 increase in gas prices is making Al Gore seem more like a wise prophet than a kook to a wide swath of the public, but whether real leadership about cost containment or Godot will come first is anyone's guess.

The alternative to the big bang approach (crisis + leadership) to changing public values is a "chipping away" strategy. Publicity about the U.S. Preventive Services Task Force recommendation that men over 75 should not be screened for prostate cancer is just the type of story that can nudge a bit of values change.

The Task Force concluded that PSA testing of asymptomatic men over 75 is likelier to cause harm than benefit. Prostate cancer that has caused no symptoms and is not detectable on clinical examination grows so slowly that elderly men typically die of other causes before the nascent prostate cancer acts up. Since treatment has many negative effects (quite apart from what it costs), a "don't ask, don't tell" non-screening approach makes most sense.

But most of the stories about the Task Force recommendations emphasized that men who want to be tested will and should have the test paid for. Over time I hope this proves wrong. If I want to have a PSA test when I'm over 75, despite learning that it's likelier to cause harm than to provide benefit, why should you pay for it? From an ethical perspective, it seems right that I should have access to the test, but should be expected to bear (more of) the financial burden myself.

This is the basic concept of value based insurance design (see here). Having a PSA test when I'm an asymptomatic 80 year old may serve my values. But the allocation of public funds should be driven by public values, not by each individual's choices. That's not where our dominant public values are at present, but it's where we have to get to if we truly want to control health care spending.

(A New York Times article about the Task Force report is available here. See here for an Annals of Internal Medicine article summarizing the Task Force's research.)