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NY Times- Health Reform, a Cancer Offers an Acid Test

By DAVID LEONHARDT, It’s become popular to pick your own personal litmus testfor health care reform.For some liberals, reform will be a success only if it includes a newgovernment-run insurance plan to compete with private insurers. Formany conservatives, a bill must exclude such a public plan. Forothers, the crucial issue is how much money Congress spends coveringthe uninsured.My litmus test is different. It’s the prostate cancer test.

The prostate cancer test will determine whether President Obama andCongress put together a bill that begins to fix the fundamentalproblem with our medical system: the combination of soaring costs andmediocre results. If they don’t, the medical system will remain deeplytroubled, no matter what other improvements they make.The legislative process is still in the early stages, and Washingtonis likely to squeeze some costs out of the medical system. But thesignals coming from Capitol Hill are still worrisome, because Congresshas not seemed willing to change the basic economics of health care.So let’s talk about prostate cancer. Right now, men with the mostcommon form — slow-growing, early-stage prostate cancer — can choosefrom at least five different courses of treatment. The simplest isknown as watchful waiting, which means doing nothing unless latertests show the cancer is worsening. More aggressive options includeremoving the prostate gland or receiving one of several forms ofradiation. The latest treatment — proton radiation therapy — involvesa proton accelerator that can be as big as a football field.Some doctors swear by one treatment, others by another. But no onereally knows which is best. Rigorous research has been scant. Aboveall, no serious study has found that the high-technology treatments dobetter at keeping men healthy and alive. Most die of something elsebefore prostate cancer becomes a problem.“No therapy has been shown superior to another,” an analysis by theRAND Corporation found. Dr. Michael Rawlins, the chairman of a Britishmedical research institute, told me, “We’re not sure how good any ofthese treatments are.” When I asked Dr. Daniella Perlroth of StanfordUniversity, who has studied the data, what she would recommend to afamily member, she paused. Then she said, “Watchful waiting.”But if the treatments have roughly similar benefits, they have verydifferent prices. Watchful waiting costs just a few thousand dollars,in follow-up doctor visits and tests. Surgery to remove the prostategland costs about $23,000. A targeted form of radiation, known asI.M.R.T., runs $50,000. Proton radiation therapy often exceeds$100,000.And in our current fee-for-service medical system — in which doctorsand hospitals are paid for how much care they provide, rather than howwell they care for their patients — you can probably guess whichtreatments are becoming more popular: the ones that cost a lot ofmoney.Use of I.M.R.T. rose tenfold from 2002 to 2006, according tounpublished RAND data. A new proton treatment center will openWednesday in Oklahoma City, and others are being planned in Chicago,South Florida and elsewhere. The country is paying at least severalbillion more dollars for prostate treatment than is medicallyjustified — and the bill is rising rapidly.You may never see this bill, but you’re paying it. It has raised yourhealth insurance premiums and left your employer with less money togive you a decent raise. The cost of prostate cancer care is one smallreason that some companies have stopped offering health insurance. Itis also one reason that medical costs are on a pace to make thefederal government insolvent.These costs are the single most important thing to keep in mind duringthe health care debate. Making sure that everyone has insurance,important as that is, will not solve the cost problem. Neither will anew public insurance plan. We already have a big public plan,Medicare, and it has not altered the economics of prostate care.The first step to passing the prostate cancer test is laying thegroundwork to figure out what actually works. Incredibly, the onlyrecent randomized trial comparing treatments is a 2005 study fromSweden. (It suggested that removing the prostate might benefit menunder 65, which is consistent with the sensible notion that youngermen are better candidates for some aggressive treatments.)“There is no reason in the world we have to be this uncertain aboutthe relative risks and benefits,” says Dr. Sean Tunis, a former chiefmedical officer of Medicare.Drug and device makers have no reason to finance such trials, becauseinsurers now pay for expensive treatments even if they aren’t moreeffective. So the job has to fall to the government — which, afterall, is the country’s largest health insurer.Obama administration officials understand this, and the stimulus billincluded money for such research. But stimulus is temporary. Thecurrent House version of the health bill does not provide enoughlong-term financing.The next step involves giving more solid information to patients. Afascinating series of pilot programs, including for prostate cancer,has shown that when patients have clinical information abouttreatments, they often choose a less invasive one. Some come to seethat the risks and side effects of more invasive care are not worththe small — or nonexistent — benefits. “We want the thing that makesus better,” says Dr. Peter B. Bach, a pulmonary specialist at MemorialSloan-Kettering Cancer Center, “not the thing that is niftier.”The current Senate bill would encourage doctors to give patients moreinformation. But that won’t be nearly enough to begin solving the costproblem.To do that, health care reform will have to start to change theincentives in the medical system. We’ll have to start paying forquality, not volume.On this score, health care economists tell me that they are troubledby Congress’s early work. They are hoping that the Senate FinanceCommittee will soon release a bill that does better. But as Ron Wyden,an Oregon Democrat on the committee, says, “There has not beenadequate attention to changing the incentives that drive behavior.”One big reason is that the health care industry is lobbying hard forthe status quo.Plenty of good alternatives exist. Hospitals can be financiallypunished for making costly errors. Consumers can be given more choiceof insurers, creating an incentive for them to sign up for a plan thatdoesn’t cover wasteful care. Doctors can be paid a set fee for someconditions, adequate to cover the least expensive most effectivetreatment. (This is similar to what happens in other countries, wheredoctors are on salary rather than paid piecemeal — and medical care ismuch less expensive.)Even if Congress did all this, we would still face tough decisions.Imagine if further prostate research showed that a $50,000 dose oftargeted radiation did not extend life but did bring fewer sideeffects, like diarrhea, than other forms of radiation. Should Medicarespend billions to pay for targeted radiation? Or should it helpprostate patients manage their diarrhea and then spend the billions onother kinds of care?The answer isn’t obvious. But this much is: The current health caresystem is hard-wired to be bloated and inefficient. Doesn’t that seemlike a problem that a once-in-a-generation effort to reform healthcare should address?E-mail: Leonhardt@nytimes.com