Rationing Healthcare and the Emperor’s New Clothes
A recent blog post at Terra Sigillata really disturbed me. The author describes how, in the face of increasing healthcare costs, Medicare now declines coverage of life saving medicines for lymphoma patients. This is one example of rationing healthcare that will become ever more common (as it is in other leading industrialized nations) as we move towards further cuts in government programs and funding. In Canada, expensive chemotherapies are not commonly covered by the national health plan, and in Britain, age is a determinant for transplant eligibility.
But what troubles me about the apparent capriciousness of denying coverage to certain types of cancer patients over others, is that government programs are – at the same time – allocating millions of dollars to researching implausible alternative medicine treatments while denying coverage of proven therapies to patients who will likely die without them.
Take homeopathy, for example. The National Center for Complementary and Alternative Medicine lists homeopathy as an eligible area of research, and boasts several ongoing studies in the area of stroke, dementia, fibromyalgia, and prostate cancer. And yet, there is no plausible mechanism of action to support its potential use as anything more than a placebo. Homeopathy operates on the assumption that water has memory, and that once it has been exposed to certain substances, such as arsenic, it obtains curative properties for illnesses that bear resemblance to poisoning from those very substances (though the water itself may no longer contain a single molecule of the substance).
Research into scientifically implausible theories should not be funded by our tax dollars at the expense of offering life saving treatments to cancer patients. It is time for scientists to stand up and point out that the Emperor has no clothes when it comes to homeopathy and other similarly flawed alternative medical treatments.
As we move towards rationing limited healthcare resources, we have a moral obligation to prioritize the money correctly. “Open-mindedness” is no excuse for poor stewardship.
Dr. Wallace Sampson sums this up in a provocative recent editorial. Here is an excerpt:
We now see accumulation of useless information in journals and information data bases — hundreds of clinical trials (RCTs) on implausible methods, such as homeopathy, unrefined plant products, prayer, and acupuncture. Initial plausibility retreats before two 20th-century development ideologies of relativism — a principle that all facts and opinions have equal or similar value, and postmodernism — that regards facts as social constructions.
Once thought to be too esoteric for relevance to medicine, these twin ideologies now mold the thinking of policy makers and granting agency officials. Ancient and traditional cultural practices are not diminished for lack of plausibility, but are investigated by RCTs because they are there.
Plausibility depends on prior reliable observations, physical and chemical laws, pharmacological principles, and advocates’ economic and legal misadventures. The National Center for Complementary and Alternative Medicine spends $100 million/year on implausible research and training grants. In performing RCTs on implausible proposals, clinical research has taken a wrong turn and departed from rationality.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
Thanks Val for this courageous post. I agree with your call for prioritizing based on good science and public benefit. I do not think it appropriate to go after the NCCAM the way you suggest, and Dr. Sampson dimisses the whole budget as “implausible research”. Americans spend more than 10 million on alternative therapies, many which need to be studied. Showing that homeopathy is placebo therapy may save countless wasted dollars in the future.
Well, Joe – I may respectfully disagree with you here. Implausible therapies (not plausible ones, of which there are some in the CAM camp) are, in my opinion, a drain of research resources. Sampson may go too far in his criticism of NCCAM, but his points about relativism and postmodernism are interesting and relevant. It is obvious that water does not have memory, just as it’s obvious that the earth is not flat, and I wouldn’t recommend spending time, energy, and resources re-testing that hypothesis either. I believe that the scientific community should take a stand against wasted resources and not legitimize obvious foolishness with tax payer dollars.
Val,
Rationing healthcare is an economic imperative, but we’re Americans and Americans don’t ration.? So we’ve deputized the government and the insurance companies to do it for us – covertly.
And you’ve put your finger on a big part of the problem with covert rationing. When you’re rationing covertly (instead of openly and transparently), you’ve got to ration according to what you think you can get away with, rather than what makes the most sense in terms of equity and effectiveness. As Terra Sigillata points out in the article you cite, “Perhaps CMS is simply counting on the fact that lymphoma patients might not have the same numbers or political clout as prostate and breast cancer advocacy groups.” And they certainly don’t have the same clout as purveyors of medical woo.
This summer, a former medical director of CMS admitted publicly that when faced with a) expensive new medical technologies, and b) official Medicare policy that says cost cannot be taken into account when deciding whether to cover such technologies, sometimes CMS has no alternative but to covertly alter the criteria for coverage, that is, “the evidence threshold for coverage is implicitly adjusted based on a qualitative judgment about the economic impact of the decision.”? (See: http://covertrationingblog.com/wonkonian-rationing/former-cms-official-admits-to -covert-rationing). Sounds like that may have happened with the lymphoma therapy.
At the risk of revealing the depth of my cynicism regarding covert rationing, I also have wondered whether the inexplicable welcome shown lately by NIH and other prestigious medical establishments to highly implausible forms of “alternative medicine” might also be explained by covert rationing. By tacitly encouraging within the population the belief that this stuff may be real, we may encourage patients (who feel increasingly put off by the healthcare system anyway) to spend a few months or years on fruitless woo before seeking real healthcare. During this interval, self-limited diseases may disappear; more serious diseases may pass through the more expensive, treatable stages. So it’s a win-win.
DrRich
http://covertrationingblog.com
Thanks for your post, Dr. Rich. I enjoyed reading your blog for the first time today. I think we have a lot in common. This post is obviously just the tip of the covert rationing iceberg, isn’t it?
Val, I am not a supporter of homeopathy, but I do respect Wayne Jonas, MD. He was the first NCCAM director and has strong academic credentials. He grew up in Germany where his father was a chaplain. He saw the role of homeopathy on their health system. He conducted a rigorous meta-analysis of homeopathy which was published in the Annals of Internal Medicine: http://www.annals.org/cgi/content/abstract/138/5/393