The National Institutes of Health explain the fundamental driver of the trend increase in health costs much better than I could:
In the past 40+ years, NIH funded research has successfully reduced the mortality and morbidity of once acute and lethal diseases and conditions by finding ways to improve treatment — even in later stages. These advances have moved what had been to acute to chronic diseases, to diseases that are chronic and manageable. These chronic diseases now form the largest component of health burden.
National Institutes of Health FY 2010 President’s Budget, page 3
A touch of hubris here – the NIH is much the biggest fish in the pond, but not the only one – but pardonable. In short: we die of things less, and live longer as permanent patients.
The great medical achievements of the NIH and its fellows worldwide are leading us (see my previous post) to an economic and social catastrophe. On current trends in medical costs, either all rich countries go broke sooner (USA) or later (rest of OECD), or we have extensive rationing of cutting-edge medicine by the market or the state, or we just leave the discoveries unused and settle for an iron rice bowl. (To be complete, or something turns up.) In homage to Jonathan Swift, who 300 years ago imagined the horrors of immortality without a stop to aging, let’s call this unsustainable situation a Struldbrug box. What’s the NIH plan for getting us out out of it?
The next sentence gives their reply:
Biomedical research is the key to transform medicine from the curative health care paradigm of the past where we intervened late in the natural history of a disease, to a preemptive model in which the onset of disease is significantly delayed or even never allowed to develop.
A bit lame, isn’t it? As commenter npm pointed out on my previous post, prevention is no guarantee of cheapness. Instead of expensive lifelong treatment, we may end up with expensive lifelong prevention. The model for optimism is the polio vaccine; the reality may be more like insulin therapy for diabetes. Scarred by over-hyped and premature announcements of silver bullets for cancer etc just round the corner, the NIH no longer dares highlight the powerful word cure. But can someone explain to me why the sort of deep knowledge that would give us a one-shot preventive vaccine against AIDS might not just as likely provide a six-pill cure? Either way, the cost problem is solved.
In the long run, possibly. But before that we are all broke. As far as medical costs are concerned, the current research strategy amounts to “that’s not my department“. I can’t find evidence that the NIH, which spent $30.6 bn last year, takes medical costs at all seriously. It’s a vast and complex organisation, and presumably there are people inside it who worry about the problem, but it’s not evident in the public face. Cost control is not mentioned in the mission statement, nor does it seem a be a specific funding area. Googling for “cost reduction” in the grants area drew a blank, “low-cost” returned only 22 hits.
I did find one programme out of hundreds that really fits the bill: significantly in the outlying, engineer-driven technology area:
RFA-HG-10-012: Revolutionary Genome Sequencing Technologies
The $1000 Genome. The timidity shows in the headline number. DARPA would have put $100: and why not? Moore’s law continues to operate; electronic widgets will become not only cheaper, but much cheaper over time. Even a mere SF reader like me can see that you make the sequencer an automated solid-state microfluidics array, shove in a fast wifi connection so you can updump the massive parallel processing to the cloud…) The Pentagon spends research pin money on robot infantry and armed dolphins. The NIH is stll thinking inside its (large, well-furnished, highly esteemed) box.
The NIH isn’t alone. The UK Medical Research Council is a high-class outfit that funded Watson, Crick, Wilkins and Franklin to crack the DNA code (guess the gender of the one who didn’t get the Nobel prize. Update: Commenter Warren Terra points out that Franklin died before the prize was awarded for the DNA code, so it’s not the Nobel committee that should be blamed for the lack of proper credit.) Annual grants run at £758 million. The website shows the same pattern. There’s no strategic objective mentioning cost control. Searching the website, “low-cost” – which you would use to publicise results – returned 27 hits, “cost reduction ” – words you would put in an objective – nil.
My third guinea pig was the Wellcome Trust, SFIK the world’s largest medical research charity. It was founded and richly endowed by one of the distant British progenitors of the GSK pharma behemoth, and awarded £628m in grants in 2010. Again, nothing about cost reduction in the strategic objectives. The search hits predictably gave only 2 for “cost reduction”, neither in the grants area, but 148 for “low-cost”. When you look at these, many of them come from projects to tackle Third World health problems, such as TB diagnostic kits.
This fits. Researchers on African diseases think about costs all the time. The Gates Foundation funds field programmes in poor countries not research, so it’s only an analogy, but the website returned 222 hits for “low-cost”. There’s a new initiative led by Norway to reduce the cost of the latest malaria treatments from $6-10 a head by an order of magnitude to <$1. This would be pointless in rich countries, but for an African peasant living on $1 a day, a $10 treatment for his child may be out of reach. A treated mosquito net in Africa, cost £4.
The malaria people are the model for rich countries. We are all African peasants in that we live under binding resource constraints, and best-practice medicine is becoming unaffordable everywhere under these constraints. The result is avoidable damage to health. Hippocrates’ first principle – which I used as the title for this post – requires that physicians take the problem seriously. So here is my recommendation to the NIH, MRC, Wellcome, and anybody else in the trade who might be listening:
Medical costs are a health problem.
This looks a tautology but isn’t. Medical costs are also correctly seen as an economic problem since medical care has opportunity costs. The patient, her fellow-insured and the taxpayer all have other things they could do with the money to pursue their individual and collective happiness. Formally speaking, this would still be true if we all only paid $1 a year, but the effect would be trivial. Today, in Ougadougou and Brighton and Santa Monica, the crowding out is frighteningly high and getting worse all the time. The economic problem has health effects, since nobody does or can give lexical priority to all health expenditure. Those who pay for medical services do not in practice pay for state-of-the-art care for all (though I guess the Nordics still come close). Doctors will regret these choices, but they are part of the world we live in.
Unafforded care has health consequences. These are large and serious. A 2009 Harvard study put the annual mortality associated with lack of health insurance in the USA at 45,000. In countries with universal care the mortality from lack of access is lower, but not negligible. In the UK there are surely deaths from rationing: for instance, there are too few oncologists. You can in principle measure these deaths and morbidities, even if it isn’t done enough.
By this route, the economic constraints and choices behind unafforded medical costs penetrate the membrane guarding the medical world and become a set of health problems: and meeting health problems is what that world does for a living.
The response generally preferred by the profession, like others, is to grumble about the choices their environment makes, to blame the deciders for the results, and to try to lobby away the constraints. Understandable, but inadequate. First, it’s not going to work, entirely. Second, the current pattern of treatment and its cost burden also reflects choices made in the past within the medical world over organisation (mega-hospitals vs. primary care) and in research (under-investment in malaria and STDs). Doctors are much more likely to have low-cost treatments and diagnostics if we look for them systematically and purposefully than by looking under the streetlights of current programmes and priorities. As Pasteur and later Fleming said, “fortune favours the prepared mind”.
So my recommendation 2 follows from 1 and the Hippocratic oath:
Making medical innovation affordable should be a major priority for medical research.
These people know their trade, and I’m sure they can think up better ways of carrying out my recommendation than I can. I’ll still kick a few cans down the road in my third and final post in this series.
To anticipate two objections.
1. It’s unethical to internalise the necessary and external evil of rationing in medical research, which should single-mindedly devote itself to expanding human capacities for intervention to promote better and better health.
Reply: (a) Bollocks to the ivory tower. Tell that to the African peasants. Medical research is part of medicine, and must address the needs of patients in the real world.
(b) Rationing is an evil insofar as it creates ethical dilemmas and unreasonable burdens for carers and patients. To the extent these harms can be avoided, they should be (Hippocrates). The choice in research between a cost-reduction project (for at least equal health outcomes) and a treatment-improvement project (involving equal or higher costs) is not a true dilemma; as they can both be assessed against the metric of ultimate improved health outcomes.
2. It would be terrible to subject all medical innovation to a cost metric. Wouldn’t that mean that you would never spend money on say better treatments for spina bifida?
Reply: Quite right and I am not proposing any such thing. The idea is to bend the overall cost curve for applied medical innovation, not in every area. Success in reducing costs in any area will reduce the cost pressure on others. By the same token, it would be absurd to impose a top-down cost ceiling for innovation in advance. No research plan survives contact with the enemy, and serendipity will rule the actual payoffs.