The Health Care Lottery

By John Ballard

Guest poster at Maggie Mahar's blog, Dr. Nortin M. Hadler, M.D., Professor of Medicine and Microbiology/Immunology at UNC Chapel Hill�s School of Medicine, lays out the odds when you go to the doctor.

I can relate to what he writes because I have been blessed with good health and required virtually no medical care all my life. But when I graduated to Medicare in April and reported for my first government-paid physical (which cost several thousand dollars after adding together all the tests, drugs, premiums, co-pays and loose ends) I now am supposed to be taking three pills a day, presumably for the remainder of my time on earth. From what I have observed taking care of other seniors, that could be just the beginning.

This makes me want to stop taking the pills altogether.

Treating high cholesterol: Let�s assume you are a perfectly well middle-aged man who learns that his cholesterol is above the level some committee defined as normal. Now you�re worried. You have a �risk factor� for heart disease, stroke and death before your time. Naturally you feel relieved that your doctor can pummel your cholesterol below the upper limits of normal if you take her favorite statin drug. Few can refuse. Even fewer pause to wonder whether the result of doing so is meaningful to them. It turns out that if I treat 100 men with a statin and 100 with a placebo, after 5 years 96 would be alive in both groups. Of the 4 who died in each group, 2 died of a heart attack. I wonder if these men would be as worried by their �high cholesterol� if they knew that their risk of death was 2% in 5 years with or without treatment. Of the 96 still alive and taking a statin, 4 had survived a heart attack. Of the 96 still alive on placebo, 6 had survived a heart attack. So if 100 men swallow a statin every day for 5 years, 2 might be spared the experience of a non-fatal heart attack. That is a surprisingly meager �win� for swallowing 1,800 pills.

Here�s where the lottery mentality leads us astray. The odds of winning a lottery are orders of magnitude less than 2%, yet many go for the win and someone will win. But the 2% reduction in risk on a statin does not guarantee anyone will win. In a randomized controlled trial 2% is right on the cusp of unbelievably small. Such small differences often do not reproduce when the trial is repeated. That means you do almost as well on the placebo and maybe as well. That�s like winning the lottery without buying the ticket. When the effect size is very small on a randomized controlled drug trial, the thinking should not be �someone wins� but maybe I would win without the risks of taking the drug.

I won�t even let anyone check my cholesterol, or PSA for that matter. I never submit to screening unless the test is accurate, the disease is important, and something important can be done about it.

That's just a sample. He coversa couple other medical conditions as well, but the main point is that how we pay for medical care is just as much a gamble as actually getting effective care.

I understand that the citizenry of most states consider playing the state lottery a morally defensible exercise. Turning health care into a lottery is morally indefensible.

Footnote:
I got my seasonal flu shot this afternoon from the public health department. But before I found out everyone else in this county is out of vaccine at the moment I placed a call to the clinic where I had my physical.
I waited so long on hold for a "phone nurse" that I gave up and struck out on my own to check the retail pharmacies. But during the time I was on hold listening to the "all nurses are busy" recording, I heard sales pitches for the clinic and other time-filling jabbering, including, believe it or not, a suggestion that I ask about a whole body CT scan to see if everything was okay or maybe they could find something wrong ahead of time.
I saw dollar signs flashing before my eyes and heard an old fashioned cash register chime in the distance.