So much for comparative effectiveness

The Obama administration’s commitment to cost control in health care can now be summed up in four words: Not on our watch.

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Health and Human Services Secretary Kathleen Sebelius told American women recently that they have nothing to learn from the science that led to the U.S. Preventive Services Task Force guidelines on mammography. Insurance companies won’t change their payment policies, and the independent doctors and scientists who made up the USPSTF task force “do not set federal policy” or “determine what services are covered by the federal government.”

What a golden opportunity has been missed to educate Americans about the implications of their health care choices. Otis W. Brawley, the chief medical officer of the American Cancer Society, in an op-ed in the Washington Post condemning the USPSTF guidelines, confirms that mass screening would only save at a maximum 600 out of the 4,000 women under 40 who die of breast cancer annually. What he failed to point out is that 1.14 million American women would have to be screened annually for ten years to achieve that goal. To cover the entire cohort (all women between 40 and 49) to replicate that benefit every year would require screening 11.4 million women annually. The cost, at $200 per mammogram (my initial estimate was accurate, according to this New York Times business section article), would come to $2.24 billion annually for the health care system.

I repeat my argument from Tuesday. Let’s start on day one and ask this question: The health care system (you can’t say the government in our mixed public and private payer system) has just come up with an extra $2.24 billion to spend on reducing breast cancer mortality in the U.S. population. Not only that, we get to spend it year after year. Should we spend it on mammography for women under 50? Or should we target that money for free mammograms for women of all ages who smoke, who are obese and who have a family history of breast cancer? Should we target that money to free mammograms for women of color, who have a much higher risk of breast cancer (perhaps because they are more likely to smoke or be obese)?

And as far as the coverage is concerned, I have yet to see a single story that quantified the harms of mass screening. How many false positives and unnecessary biopsies are there for every breast cancer caught early? How many actual, treated positives turn out to be very early stage ductal carcinoma in situ, minor breast duct growths that may dissolve on their own? A recent AHRQ analysis suggested that was about 20 percent of all growths identified during mammograms. According to Dr. Greg Pawelski’s most recent comment on GoozNews:

Research by the Nordic Cochrane Centre in Denmark raised questions about the effectiveness of mammography. In a study of 2000 women, they found that one woman would have her life prolonged but 10 would undergo unnecessary treatment and 200 women would experience unnecessary anxiety because of false positive results.

Health care is complex. Most treatments that “work” only work in a fraction of the people who get that treatment. Each has risks, which also affect a subset of those treated. Evaluating value is a trade-off between risks and benefits. Because breast cancer is such a high profile issue, the new mammography guidelines offered the Obama administration a chance to educate the public about the trade-offs involved in making those choices, and how the nation might wring more value out of the money it spends on health care.

Alas, the administration punted. In the midst of a political battle over health care reform, where nihilist Republicans are braying about profligate spending on the one hand and letting nothing stand between you and your doctor on the other, the politicians in charge of health care policymaking saw that offer as one they had to refuse.