post by Paul Kelleher
There is a saying in health policy (I don't know where I first encountered it):
Necessity is the mother of invention, except for in medical care, where it's the reverse.
So long as a medical intervention has at least marginal benefit and is medically indicated for a patient, it tends to be treated as "medically necessary." This is a huge problem.
Yesterday I quoted Dr. Virginia Hood's explanation of why the American College of Physicians used the word "parsimonious" in this guideline from the College's recently released Ethics Manual:
"Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available."
Dr. Hood had this to say about that choice of wording:
"Parsimonious is a good word in the sense that it means that you use only what's necessary," she said.
If you are reading this blog post, then you are probably comfortable with the idea of Comparative Effectiveness Research (CER), whose main goal is to determine "what works." And there is great hope among health policy scholars that the U.S. can hem in the growth of health care expenditures simply by eliminating care that does no good at all (or which may even be harmful). Sometimes this is even referred to in the biz as "low hanging fruit." But the flipside of CER is that it also highlights those many treatments, screening protocols, etc. that do in fact "work." Many of these interventions will yield significant benefit that we will want everyone to have access to. But some--and perhaps many--will provide marginal benefit only. Should these treatments be considered "necessary"? After all, given a large enough population, it is a statistical certainty that providing these treatments will prevent early deaths that would have occurred without them.
It has been said that we now live in a "risk society," where the main threats to health for most of us are not immediately fatal threats, but ones that marginally increase our risk of early death and illness. In such a risk society, there is great danger in letting "marginally beneficial" = "medically necessary." For while there will always be more that we can do to lower already small risks to health, each incremental reduction will tend to be more and more expensive as the low hanging fruit is picked. Instead of instinctively picking the remaining and very very expensive fruit, we are going to have to get better at picking our battles. This is where cost-effectiveness analysis and the American College of Physicians' open mind will be of great use (neither is a silver bullet). That said, we clearly still have a long long way to go, as I think Virginia Hood's definition of "parsimonious care" makes plain.