Hi Ben
An interesting thread - thanks for raising this.
First off, there is an assumption that the rising health care costs will become unaffordable. But ... has pointed out that as we become wealthier the proportion of GDP spent on luxuries, including health, increases. Of course, as Stephen Senn pointed out (comparing the USA and Cost Rica), spending more doesn't always provide a gain in health.
But assuming we did want to constrain costs, then there seem to be 2 categories: do less or do it cheaper. So spell those out:
1. DO LESS THINGS
There are several options here.
We might do this by doing less useless things (cutting waste). For example, vertebroplasty for osteoporotic fractures was costing the US about $1Billion per year, but the two RCTs that used a sham control showed no benefit. This is just one of a very long list.
We could also cut costs by doing the same things better - which quality improvement aims to do (Stephen Senn points this out with the link to the Brent James talk). Another example is Peter Pronovosts' work to reduce central line infections, which saved lives and money (from less ICU time).
Finally we could also do less "useful" things - which is where the New York times article and our attitude to death comes in. As a footnote to this, there was a very interesting study in the NEJM showing palliative care
2. DO THINGS CHEAPER
One option is to get a better price. For example, generic drugs may lower costs but only if competition works correctly. And - as Jeremy Howick pointed out - some "me-too" drugs may have marginal benefits but at much higher prices. So buyers might be more savvy in purchasing treatments - asking whether any incremental gain is worth the higher price (as the PBS in Australia has done for about 20 years now).
But prices can be lowered in other ways. For example, Fred Hollows made cataract surgery affordable in the developing world by training local docs to do it, and building local factories that could produce a lens for $1. Similarly, trials have shown that an empty Coke bottle can have a hole cut in the bottom and be used as a "spacer" for asthma aerosols, or can be used to sterilize water using sunlight.
Paul Glasziou
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From: Evidence based health (EBH) [[log in to unmask]] On Behalf Of Djulbegovic, Benjamin [[log in to unmask]]
Sent: 15 July 2011 14:03
To: [log in to unmask]
Subject: solution to health care cost crisis: technical vs.philosphical..
In light of repeated discussion of unsustainable rise in health care costs that is threatening to undermine all other aspects of the way modern society functions, I attached the article from this morning NYT. The author argues that a technical solution to health care crisis is not feasible, but instead a solution lies in the way we deal with our own mortality. Understanding and accepting death as an integral aspect of human life- and hence not clinging to (expensive) medical interventions that are devised to “marginally extend the lives of the very sick” may provide the avenue to the current financial crisis that appears to be largely driven by health care costs.
Provocative and intriguing thoughts to which no one can remain indifferent….and I am looking forward to reading further insightful comments from the members of this group…
Best
Ben
Benjamin Djulbegovic, MD, PhD
Distinguished Professor
University of South Florida & H. Lee Moffitt Cancer Center & Research Institute
Department of Medicine
Chief, Division of Evidence-based Medicine and Health Outcomes Research
Co-Director of USF Clinical Translation Science Institute
Director of USF Center for Evidence-based Medicine and Health Outcomes Research
Mailing Address:
USF Health Clinical Research
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