Even best medical reporting infected with “make do” bias

June 19, 2013 — Elisabeth Rosenthal’s front-page story in The New York Times two weeks ago carried quite an ambitious subhead: “Colonoscopies Explain Why U.S. Leads the World in Health Expenditures.”  In important respects, her article met its ambitions, most particularly in explaining the consequences of this country’s failure to regulate pricing for the medical services received by most of the population (a failure that treats health care as though it were a commodity no different from a toaster or a DVD player). Rosenthal also made a convincing case that lobbying (in this case by a professional association of anesthesiologists) has effectively kept medical costs higher than they need to be.

But Rosenthal was not immune to the popular phenomenon of overplaying over-treatment and underplaying under-treatment, a topic that Remapping Debate reported on earlier this year. In a similar vein, she failed to appreciate the importance of searching for the best treatment, as opposed to focusing exclusively on reducing the cost of care at the current level. Finally, her point about price variability could have been made better — if less dramatically — by honing in on what most procedures cost, not the procedures at the 5th and 90th percentiles.

Hear no market evil, see no market evil, speak no market evil

Rosenthal made clear a fundamental point about medical pricing. The United States, she noted, is “unique among industrialized nations” in not regulating or intervening in medical pricing (other than in connection with rates for Medicaid and Medicare). 

And this isn’t a function of all the other industrialized countries having abandoned fee-for-service systems:

“Many other countries,” Rosenthal wrote, “deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example.”

Rosenthal quoted Dr. David Blumenthal, president of The Commonwealth Fund and a former advisor to President Obama: “In the U.S., we like to consider health care a free market…But it is a very weird market, riddled with market failures.”

One manifestation of an unregulated market: gaming the system to maximize profits. Thus, for example, Rosenthal’s explanation of the growth of outpatient surgical centers.

“When popularized in the 1980s, outpatient surgical centers were hailed as a cost-saving innovation because they cut down on expensive hospital stays for minor operations like knee arthroscopy,” she wrote. “But the cost savings have been offset as procedures once done in a doctor’s office [like colonoscopies] have filled up the centers, and bills have multiplied,” she concluded.

Turf wars

As Rosenthal pointed out, a significant part of the cost of many colonoscopies is the cost of the participation of an anesthesiologist, even though colonoscopies require only moderate sedation (provided by a “Valium-like drug or a low dose of propofol,” sedation that, in other countries, is “administered in offices and hospitals by a wide range of doctors and nurses for countless minor procedures, including colonoscopies”).

Why are anesthesiologists so much a part of the colonoscopy picture here? Because when propofol was first approved as an anesthesia drug by the FDA, the agency issued an advisory that the drug should be “administered only by those who are trained in the administration of general anesthesia” (that is, anesthesiologists), and, despite evidence that lower doses can be safely administered without an anesthesiologist, “the American Society of Anesthesiologists has aggressively lobbied for keeping the advisory, which so far the F.D.A. has done.”

Are we really too casual in prescribing colonoscopies?

Way too casual, to judge from the article. The one-sided information provided on this point represented one of the article’s principal sins.

Here’s Rosenthal’s take, consistent with the overuse mantra that the Obama Administration embraces and that has swept the country more widely: “While several cheaper and less invasive tests to screen for colon cancer are recommended as equally effective by the federal government’s expert panel on preventive care — and are commonly used in other countries — colonoscopy has become the go-to procedure in the United States.”

And this: “[S]tudies have not clearly shown that a colonoscopy prevents colon cancer or death better than the other screening methods. Indeed, some recent papers suggest that it does not, in part because early lesions may be hard to see in some parts of the colon.”

For a facile quote on the supposed absurdity of performing so many colonoscopies, Rosenthal turned to a representative of the highly influential organization that is as reflexively against expensive options (independent of utility) as the most self-interested physician lobbying group could be in favor of them: “‘We’ve defaulted to by far the most expensive option, without much if any data to support it,’ said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.”

Remarkably, however, Rosenthal failed to cite a 2012 study, the lead author of which was Dr. Nancy Baxter, an associate professor of surgery at the University of Toronto and St. Michael’s Hospital. That study, a large U.S. population-based case-control study showed that colonoscopy was associated with a material reduction in the odds of colon cancer mortality, “indicating a substantial protective effect.”