For all people invasive cancers, blocked arteries and infections need preventions and treatments that work. Those of us who can afford such care owe it to those who can’t. But if we are taxed to pay for care of others that is unnecessary or ineffective - care that does not work - our system will be rejected by a resentful public. A sustainable health care model must distinguish services which are worth taxpayer support and which are not.
Services often excluded are assisted suicide, cosmetic surgery, meditation and yoga. Many insurance plans exclude adult dental, eye, hearing and foot care. Some exclude treatment of addictions and obesity, gender change and erectile dysfunction. Acupuncture is often excluded while chiropractic is politically favored. Lobbying by drug manufacturers sometimes prohibits purchases of generic drugs that are equally effective and less expensive than their patented counterparts.
How Are the Medical Care Decisions Made? Who Makes Them?
Decisions on issues such as assisted suicide, abortion and stem cell uses are ethical and political. Whether care is necessary, effective, and worth our sharing their costs, are scientific decisions. They are made at five levels. America’s most expert scientific level is the National Academy of Medicine, a voluntary association of eminent scientists who on request of agencies such as the Food and Drug Administration or Medicare will review proven facts and offer recommendations. Similar sources of expertise are found in Cochrane reviews based in Britain. Such agencies resist commercial advocates of worthless or dangerous treatments.
The next level of expertise consists of specialty societies, such as the American College of Physicians and the American College of Surgeons. It is in their professional self-interests to protect the credibility and prestige of their members by distinguishing and promoting good care. They do this in scientific meetings and publications. Their integrity almost always overrides any profit motives of their members.
A third level of expertise lies in the experiences of practicing specialists who are intimately familiar with how their patients have been affected by their various treatments. But their opinions on debatable issues, no matter how honest and sincere, tend to be biased in favor of procedures they have arduously practiced, especially when they are compensated for procedures rather than for results. On debatable issues, specialists make vital contributions by translating scientifically proven facts to the unique problems of their patients.
A fourth level of judgement in deciding whether to proceed with a debatable test or treatment lies with a patient’s primary care provider, family physician or general internist. He or she will have the most comprehensive knowledge of each patient, as well as knowledge of available specialists. Some knowledge of a specialist’s results and quality may be available as public information, but important opinions on a specialist’s judgement and dependability are often found amongst one’s colleagues and former patients.
The fifth and ultimate level of judgement is the patient who has been wisely informed of his or her diagnosis, prognosis and options, by a well-trained and familiar primary care provider. An informed patient is the most important decision maker. The primary care provider is a vital link between patient and the health care system, and the system’s defense against treatment that is probably useless, possibly dangerous, and more expensive than warrants public support. A successful system requires that a nation’s medical schools give appropriate prestige to primary care and minimize the debts of its graduates.
Healthcare Science vs Sales
To eliminate bias, scientists begin evaluating a theory, machine, drug or operation by assuming it does not work (a “null hypothesis”), then seek proof that it makes a difference. Manufacturers and salesmen assume their products work. Their lobbyists may put intense pressure on scientists to agree, even when evidence says it may not. Clinical trials may drag out for years, while manufacturers make small changes that require repeat trials. A sustainable health care model needs legislative support for not spending public funds on care where evidence of effectiveness is doubtful. Payment for debatable products or services should be voluntary out of pocket, through supplemental insurance, or from charities.
As our model extends necessary care to twenty million people now uninsured, scientific review panels must be more discriminating in choosing procedures for which public payment is allowed.