FOR THIS presidential campaign, healthcare is back on the radar. All the candidates agree we need more access without adding more cost.
But how? Candidates promise savings from simplifying administration, curbing cost shifting, improving insurance markets, and computerizing information systems. But no one has a good answer for the heart of the cost problem: the relentless expansion of expensive services.
Some would say the only solution is rationing. The word serves as political red meat. Say it and reform is dead for another political season. But rationing is not red meat, it's a red herring. Rationing implies the withholding of effective services that people would want after being fully informed of the benefits and associated harms.
There would be no need to contemplate rationing if we took a dose of healthy skepticism and asked tough questions about the value of medical care:
Is all medical care "effective"? No. While there's a common presumption that all medical care is effective, it's often not true. Hormone replacement in post-menopausal women, bone marrow transplantation in women with breast cancer, and stent placement for patients after heart attacks were all once promising therapies embraced by doctors and patients. But when studied in true experiments, none worked and each caused some harm. Surprisingly, much of what we do has not been rigorously studied. Without these studies, we cannot know what is effective.
Just how effective is "effective" care? Even when an intervention has been rigorously studied and labeled effective, healthy skeptics should ask: Just how effective is it? To answer this, you need to see two sets of numbers: the numbers for what happens if you use the intervention and the numbers if you don't.
Consider the drug Plavix, which helps keep blood from clotting. It has been labeled effective, but what are the numbers? In an experiment published in the New England Journal of Medicine on more than 15,000 patients with chronic heart disease, the risk of heart attack, stroke, or death in the next two years for patients who took aspirin and Plavix was 7 percent. The risk for those who took aspirin alone was 8 percent. Also, patients who take Plavix face a higher risk of serious bleeding. In fact, the number of people who experienced the benefit equaled the number who experienced the harm.
Sound like a close call? Much of medicine involves close calls - a delicate balance between benefits and harms - where different individuals in the same situation might reasonably make different choices. If patients were truly informed, many would opt for less treatment.
If something is "effective" for some, is it "effective" for all? The Plavix case also highlights a third caution: Just because something is effective for one group doesn't mean it is for another. The study included two groups: people with and without symptoms of heart disease. According to the study, if you don't have symptoms of heart disease, Plavix doesn't work. In fact, it increases your chance of death. This highlights how the benefits and harms differ depending on how sick you are.
Over $4 billion is spent on Plavix each year. Do we need to ration Plavix? No. We need to tell people the full story about this and other medical interventions.
Is medical care the best prescription for health? Improving health is about more than avoiding bad things (disease); it is also about fostering good things (well-being). When people think about improving health, too often they think about improving medical care. Too often improving medical care means providing more of it. While medical care can be an important component of health, so are a lot of other things. The most effective means to improve health might involve reallocating some of $2 trillion devoted to medical care to efforts promoting exercise, balanced diets, education, employment, and reducing poverty.
Real reform requires questioning assumptions about medical care. Healthy skepticism is more important than a new insurance market, a new quality improvement effort, or even more research. Why would this skepticism be healthy? Because it's healthy to recognize that medical care has downsides, as well as upsides, and that the path to health involves more than taking a pill or getting more medical care. It's about getting the care that will help you, avoiding the care that will hurt you, and having the wisdom to recognize all the other things that matter.
Drs. H. Gilbert Welch and Steven Woloshin are general internists at the Department of Veterans Affairs Medical Center in White River Junction, Vt., and are senior faculty at the Dartmouth Institute for Health Policy & Clinical Practice. Dr. Lisa Schwartz also contributed to this essay.
