It’s the dog days of what seems to have been an unusually hot summer (though DrRich does not know whether it has been sufficiently warm to affect the global cooling trend we’ve been in for the past decade), and as is all too common at this time of year, we are seeing extraordinarily heartbreaking stories (like this one) about healthy, robust young athletes dying suddenly on the practice fields.
Most of these tragic sudden deaths are due to a heart condition called hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy often does not produce any symptoms prior to causing sudden death. But it can be easily diagnosed, before exercise-induced sudden death occurs, by screening young athletes with electocardiograms (ECGs) and echocardiography.
A couple of summers ago, the New York Times wrote about such an athletic screening program at the University of Tennessee. Based on the U of T’s results, “cardiologists and other heart experts say that the screenings could help save the lives of the 125 American athletes younger than 35 who die each year of sudden cardiac death.”
The reason this routine cardiac screening is not widely used is because of the expense. Making the very conservative assumption that 1 million young Americans participate in athletic competition each year, and that (as the Times reports) the average cost of screening is $1,000, then screening would cost us about $8 million to save one life. That’s pretty a steep cost-effectiveness challenge by any standard.
But Dr. Douglas Zipes (the perennial New York Times expert on all matters cardiac) speaks for many of us when he says, “If it were my son playing ball, I would like him to have an echo, even though it is cost inefficient.”
In truth, the cost-effectiveness analysis here presents a problem only because the kind of screening being used is judged to be a medical service, and thus ought to be paid for through some centralized pool of money (whether the pool is controlled by insurance conglomerates or the government).
If we were to do a similar cost-effectiveness analysis on seat belts, smoke alarms, motorcycle helmets, or carbon monoxide detectors, we would reach a similar conclusion: Yes, those several hundred preventable deaths from house fires are indeed a tragedy, but we simply can’t afford to pay for smoke alarms for all those millions of American families, just to save those relatively few lives.
The difference, obviously, is that we don’t expect smoke alarms to be paid for out of public funds. We expect individuals to do their own cost-effectiveness calculation, and decide whether to buy smoke alarms from their own resources. Individuals tend to place a much higher value on their own lives than the value assigned to their lives by society (the self-assessed value of one’s own worth often approaching infinity), and therefore many people indeed find the cost-effectiveness calculation to come out in their favor. Thus, buying smoke alarms seems a reasonable investment for many individuals.
If Dr. Zipes wants his son screened by echo, by all means have it done. I agree it would be entirely worthwhile. But don’t ask me to pay for it.
It is especially noteworthy that the technology exists to place cheap, portable echocardiogram machines in the office of every primary care doctor, and every primary care doctor could be easily trained in less than an hour to rapidly screen athletes for hypertrophic cardiomyopathy. For probably less than $100, parents like Dr. Zipes could have their children screened with this kind of limited echo and an ECG at the same time they’re getting their flu shots.
But we can’t do this because a) professional groups like the American College of Cardiology will do everything they can to block the democratization of guild-based procedures like the echocardiogram (start-up companies that have developed such tiny, easy-to-operate echo machines have been very disappointed with the response of the cardiology community), and b) such screening is a medical service, and it’s generally acknowledged to be a travesty to expect (or, as DrRich points out, to allow) individuals to pay for any medical service themselves.
And if such obstacles result in the sudden deaths of a hundred or so young athletes each year (most of whom, by the way, are participating in pick-up or intramural sports, rather than the semi-pro variety we watch on TV every March), well, it’s too bad there’s nothing we can do about it.
*This blog post was originally published at The Covert Rationing Blog*