Is this the face of health care rationing?

In 1994, we were living in Southern California when the Northridge earthquake occurred. It was 6.8 on the Richter scale and took place in the early hours of the morning while we were asleep. Our house literally shook for what seemed an eternity but was actually less than a minute. It felt like King Kong had grabbed hold of the house and was literally shaking it! Our house was probably about 7 miles – as the crow flies – from the epi-center.

Several days later I was in a discussion with an associate at the company where I worked. He was a Californian – born and bred – and I told him that given what we had experienced, I could not imagine what it would be when “the big one” would strike. “The big one”, in the parlance of California, was the quake which seismologists have predicted will hit California sooner or later and would be in the magnitude of somewhere between 8 and 9 on the Richter scale. He told me something that has stuck with me ever since. He dismissed the talk about the so called “big one”, not as to whether it would happen or not but in the context of what it really means. He said that for the people who lived at or near the epi-center of the Northridge earthquake, that quake was “the big one”. It did not matter to those people if a much larger quake were to occur elsewhere several hundred miles away from where they lived – even if that was generally accepted as “the real big one”.

All of the above came to mind in the context of the controversy that has erupted in the US over changes recommended in breast cancer screening for women through the use of mammograms and self-examinations. After years during which it was recommended that women over the age of 40 years should be screened annually for breast cancer through mammograms, a task force has recommended that women over the age of 40 years don’t need to be screened unless they fall into a high-risk group and that the self-examination is not needed. After the age of 50 years, bi-annual mammograms are recommended.

If anyone wants an example of how rationing in health care works, the following excerpt from this article provides it in spades:

“Statistics from the National Cancer Institute show that the risk a woman of 40 will be diagnosed with breast cancer before she turns 50 is relatively low – less than 2 percent. But the false positive rate for those same women is relatively high – 50 percent higher than women in their 50s.

“The question is going to be, between the ages of 40 and 50, what is the frequency with which you are going to find a true positive cancer finding, how many cases would we miss, how many of those cases would develop into cancer and what is it going to cost to treat them,” said Ian Duncan, president of Solucia, a company that provides actuarial health care analysis for insurers.”

Essentially, what the task force recommended is that to avoid unnecessary costs incurred as a result of “false positives” and the cost of providing routine screening, we should be willing to accept a certain mortality rate because of failure to diagnose breast cancer at an early stage!

A fire-storm has erupted over these recommendations with the American Cancer Society and many oncologists urging that the recommendations of the task force are disregarded. Even the Secretary of Health and Human Services under whose auspices the task force worked has distanced herself from the recommendations. For my part, given that breast cancer is the most common cancer to afflict women in the US, it is difficult to fathom the logic behind the recommendation other than to save money and accept that, in the process, a certain number of cancers will just go undetected or detected at a late stage when it would most likely be fatal. No one argues – including the task force – that some women in their forties do have breast cancer detected through mammograms. The only argument is that the number of detections is not significant enough to warrant spending the funds required – never mind that the woman in her forties whose cancer is detected through a mammogram is experiencing the equivalent of “the big one” in seismological terms!

Even more bizarre is the recommendation by the task force that self-examinations for lumps are not necessary. There are cases where breast cancer have been diagnosed after a self-examination which, after all, does not cost anything – the only cost would be that incurred in any follow-up after self-examination reveals a lump. Carly Fiorina, the former CEO of Hewlett Packard, is the poster child for why self-examination is needed. Fiorina had a mammogram that was negative but a self-examination revealed a lump and a biopsy showed it to be malignant. She considers the task force’s recommendations to be outrageous – as she put it, had it not been for the self-examination she might not be alive today.

I am glad that there is outrage by women about this whole issue. The danger is that insurance companies will use the recommendations of this task force as the rationale for denying coverage of routine mammograms in the future. In a more global context, I see this as being a case of the rationing of health care rearing its ugly head – and it is in the interest of every American to resist it before such thinking is deemed “acceptable”!