Friday, November 05, 2010

How Much to Save a Smoker?

You want death panels? I got 'em right here!

The straight-news version of the CT v. x-ray chest screening test is a bag of hornets fairly buzzing to get out. The $250 million, seven year study of over 53,000 smokers concluded at its most basic that computed tomography scans were 20% more effective, in essence saving one life for every 300 scans.

Among the hornets are:
  • Even low-dose CT scans are radioactive and carry risks at the level of mammograms
  • CT is much more expensive than x-ray, at about $300 per scan
  • Most anomalies in CT scans are benign, but often lead to risky, expensive, invasive biopsies
  • Cost/benefit analysis has yet to be done, or at least not released
One of our most repeated clichés is that saving a single life is worth any expense. A corollary is that life is so precious that adding a year, a month, a week or a day to someone's span is a fundamental virtue.

Contrast that with wails of the hundreds of millions paying the world's highest per-capita health care costs, while getting rewarded with per-capita lifespans way down the list of nations (29th down). Docs like to blame the many Americans who are fat, sedentary, smokers or some combination. On the other hand, I don't see studies on the effects of the ignorance of doctors about nutrition or their system that discourages spending time with their patients while encouraging treating symptoms with drugs rather than trying to cure underlying conditions.

Regardless of causes, it would be hard to find an American who does not think health care here costs too much and provides too little.

Surprisingly, around 46 million Americans still smoke cigarettes. They know this extremely expensive habit is packaged cancer, heart disease, and emphysema. So, many of us are about as sympathetic to smokers as we used to be in the early awareness of AIDS, when the common thought was it was a disease limited to rutting gay men.

Right now, people not in such a study would have to pay for their own CT scans. Medicare folk promise to review the results here and decide whether to add this test to its structure. In that vein, note that qualification for the study included 30 pack years per smoker (two packs daily for 15 years or one for 30 years). Those in the study were all smokers from 55 through 74 years old.

The researchers apparently were charged with the science and not economic, policy or political analysis. That's where the hornets await. Consider:
  • If — shades of AIDS — people knowingly engage in risky behavior, does that devalue their right to diagnosis and treatment?
  • If CT scans save one life were 300 smokers tested, is that a test insurance, including Medicare, should pay for?
  • What is the tipping point for added longevity — one year, five, longer?
  • As CT scans include more radiation and invasive procedures, when does the cost outweigh potential benefits for a few?
  • In this environment of tight money, high health costs, and public demands to limit government spending, should smokers get triaged into low-priority test queues?
At least until recently, we as a nation were apt to say saving a single life is worth any cost. Think of the safety programs for school kids and preventative testing for everyone though old age.

I'm betting studies like this one inspire lawmakers, medical groups, insurers and others to repackage their clichés. Many may seek polite and euphemistic phrasing for what a year ago would be called death panels. Triage refers to sorting and we're likely to hear more of it.

Dr. Peter Bach at Memorial Sloan-Kettering Cancer Center in NYC already has a few presaging cautions. The NYT quotes him as, "Very soon we'll have an answer about who should be screened and how frequently, but we don't have that answer today." From the same email, the Washington Post gleaned musing on whether there will be an orderly, well-planned roll-out, or whether we shall "see an avalanche of entrepreneurial radiologists taking out full-page ads and billboards tomorrow overstating the magnitude of the benefit, and without any plan in place for how to handle whatever is found or how to select the right patients for screening?"

Either way, most addicted smokers will continue to risk diseases via cigarettes. We don't know if insurance would pick up CT scans whether those same smokers would go for them.

We are likely to hear more bottom-line talk and less expansive bluster about every moment of life being priceless.

Many wingers have long had a life dichotomy. They like to call a not-even-yet-a-fetus group of cells a baby, while many of their number favor capital punishment and mortal self-defense against burglars. Times being tight, we'll surely get some reframing of how precious they think life is for nicotine junkies.

Death panels, indeed. As Cyndi Lauper sings, "Money changes everything."

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