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July 8, 2009

A liberal view of prostate cancer

Richard N. Weltz
Wednesday's New York Times features a front-page opinion article by economics reporter David Leonhardt headlined "In Health Reform, a Cancer Offers an Acid Test."

Using prostate cancer as his "test," Leonhardt provides, unintentionally, a scary look at what's in store should Obama get Congress to start moving toward his goal of fully nationalized healthcare. Treatment of prostate cancer, the writer explains, may vary in cost considerably:

Watchful waiting costs just a few thousand dollars, in follow-up doctor visits and tests. Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.

And, there are a number of other options with costs ranging between the low and high end of these approaches. Ah, but under the "fee-for-service" basis on which our health system operates, he insists, doctors will be encouraged to go for the high-cost options even though, Leonhardt claims, nobody knows that works better.

And in our current fee-for-service medical system -- in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients -- you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

"No therapy has been shown superior to another," an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, "We're not sure how good any of these treatments are."


It's that old liberal devil, fee-for-service, that is at fault, Leonhardt maintains -- conveniently forgetting how much of our service economy: legal services, auto repair, financial advice, securities brokerage, house painting, party planning, catering, and hundreds of other functions are based on paying a fee for the service received, a fee which can vary widely according to the choices made, just as with the different medical procedures.

There is something terribly wrong, in the Leonhardt view, with a patient consulting with his doctors and jointly deciding the course of treatment for a prostate cancer diagnosis, taking into consideration the doctors' views on efficacy and the patient's views on lifestyle effects. Recently, my wife had to undergo major surgery. Her surgeon outlined several different ways that it could be performed and the pros and cons of each. Cost was not -- and should not have been -- a factor, only a consideration of what would be best for the patient.

This is decidedly not what Leonhardt, the New York Times, and other proponents of government-controlled healthcare want; and the article makes their objective quite clear. "The first step," he writes,  "to passing the prostate cancer test is laying the groundwork to figure out what actually works." The next step, although it is only described in a roundabout way, is for the government to dictate which procedure and at what price will be the one for everybody. "Doctors can be paid a set fee for some conditions," he says,  "adequate to cover the least expensive most effective treatment." Of course, it will take an army of bureaucrats to determine what is an adequate fee and what is the one-size-fits-all "least expensive most effective treatment" for every imaginable ailment.

If doctors do not always agree on a course of treatment (the reason why many insurers require second and even third opinions for some procedures), how likely is it that the bureaucrats will?

Leonhardt does admit that some decisions will be tough calls:

Even if Congress did all this, we would still face tough decisions. Imagine if further prostate research showed that a $50,000 dose of targeted radiation did not extend life but did bring fewer side effects, like diarrhea, than other forms of radiation. Should Medicare spend billions to pay for targeted radiation? Or should it help prostate patients manage their diarrhea and then spend the billions on other kinds of care?

So, let's be honest. Who would you rather have making decisions about your diarrhea, you and your doctors, or some pols in Washington? For that matter, who would you like to have making your medical decisions when your life itself hangs in the balance?

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