Ah, the seamy underside of cost-effectiveness research. Doc Gurley has done cost-effectiveness research, including published studies, in one of her many previous careers (Doc G assessment: not as interesting as waitressing, fewer tips,
more messes, fewer laughs). There is a nasty, secretive part of cost-effectiveness health research that no one publicly discusses which (shockingly!) made the news, in this article. In it, Dutch researchers admitted that the most cost effective approach to the global epidemic of obesity and diabetes is to (brace yourself for this) ignore it. Gasp. How can this be? Well, if you turn over the rock of cost-effectiveness research and take a look at what lies underneath it all, you find a pretty horrifying fact, which can be summarized by one request to all of us healthcare consumers: honey, the cheapest, best thing you can do, dollar-wise, is drop dead. Could you do that for us? Because that would be awfully cost-effective. Doc Gurley discovered this nasty secret years back when a fellow researcher earnestly explained that getting folks to stop smoking was not cost-effective in terms of healthcare. How can that be? First, a majority of people, left alone, will continue smoking, despite feeling worse and worse. Many of those smokers will then, in what is obviously an effort on their part to help rein in costs, obligingly drop dead. No hospital bills, no treatment, no doctor visits, no nothing–such a deal! Second, a number of smokers will wait until they are having symptoms from their smoking, and then they quit. In a blatant act of selfishness, those people are rude enough to use up gobs of money, because now they’ve got problems from their smoking and they just (shame on them) keep on living. How dare they? Those people who quit smoking, and, by doing so, survive, are extremely NOT-cost-effective, especially when compared to the ones who are dead. This fact remains true even after you adjust for numbers of life-years saved, even after you adjust for suffering. Therefore, what is the cost-effectiveness answer to smoking cessation? If someone has smoked for twenty years, you should encourage them to keep smoking. Or ignore it, as the Dutch researchers recommended we do with the obesity and diabetes epidemic. You don’t want long-term smokers to quit, because if they do, they’re less likely to drop dead, and more likely to be an expensive drain on the rest of us.
Taken to its logical conclusion, what the stop-smoking example and the Dutch study both reveal is the ultimate, irreconcilable conflict between profit and health. And these two examples are not unusual. Discussions about who gets to survive, and at what cost to the profit margin, are occurring all the time, whether they are reported in the news or not. When it comes to healthcare in this country, we’ve been sucked into a for-profit frenzy and gotten blinded by the gleam of the almighty dollar. Health (and life) is not a widget to be negotiated down to the cheapest, unregulated (toxic import!) price. Instead, healthcare is most like public education, or prisons, or the military, or public water, or firefighting, or police (in fact, like all the other 911 public emergency services). Cost-effectiveness is never even mentioned in the same breath as these services–we assume there is an inherent crucial benefit to society from them that is worth their impressive shared cost. In the same way, cost-effectiveness (and profit) should not be the primary goal of healthcare. Certainly not its reason to exist. Just like with public water, or schools, or police services, healthcare should be a minimum-level public service for everyone, with the option to pay more for your own extras, if you want. You want to buy bottled water? Go ahead. You want to hire a private detective? Go ahead. You want to pay for private school, sure. That’s the way we manage all our other absolutely not-cost-effective public services. Whew. Excuse me while I go lie down and recover…