Substantial Treatment Overuse in the United States?
Abstract
Re: Luce BR, Mauskopf J, Sloan FA, Ostermann J, Paramore LC.The return on investment in health care: from 1980 to 2000.Value Health 2006;9(3):146–56.
To the Editor––Bryan Luce and colleagues [1] show that medical care starting from birth has yielded a return on investment (ROI) greater than one in the United States between 1980 and 2000. A major assumption of their analysis is the price of an undiscounted life-year, set at $100,000. The authors also present the ROI of medical care for major diseases (coronary heart disease following acute myocardial infarction, type 2 diabetes, stroke, and breast cancer) between the 1980s and the 1990s. Calculations are based on Medicare data, i.e., patients at the age of 65 years and above. The ROI for each of the four disease states has been again greater than one, for breast cancer even close to five. Finally, the authors present the ROI of major treatment innovations for the diseases within the past 25 years, based on a literature search for cost-effectiveness analyses (CEAs).
It is quite striking that except for breast cancer the ROI of major treatment innovations is far higher than the ROI of all medical care for the disease in question. In fact, for coronary heart disease, type 2 diabetes, and stroke, all major treatment innovations yield a higher ROI than total medical care starting from birth. This result is even more surprising given that ROI decreases with age [2] and over time [2], i.e., more recent innovations have on average a worse ROI than earlier innovations. As Medicare, of course, covers not only recent innovations but also long-established interventions (such as basic clinical examinations), I would have expected a worse ROI for recent innovations than for all medical care provided. An important reason for this inconsistency might be that CEAs of specific treatments do not incorporate the costs of overuse, i.e., they consider only appropriate care. Hence, the large discrepancy could point to substantial treatment overuse. This would indirectly confirm previous analyses showing that some US regions have about twofold higher Medicare expenditures without better outcomes [3,4].
Still, the question remains why there is apparently no such discrepancy for breast cancer treatment. Is there less overtreatment in breast cancer than in the other diseases? Overtreatment also occurs in breast cancer patients, but it seems mostly limited to mastectomy in early stage disease [5]. Perhaps physicians adhere stronger to treatment protocols when treating breast cancer patients.
The authors did an excellent job at presenting a very detailed picture on the ROI of US medical care. Still, I believe that the main conclusion of their analysis should not be that US medical care has been worth its investment, but that ROI could be much better.
––Afschin Gandjour, MD, PhD, Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany.
References
1 Luce BR, Mauskopf J, Sloan FA, et al. The return on investment in health care: from 1980 to 2000. Value Health 2006;9:146–56.
2 Cutler DM, Rosen AB, Vijan S. The value of medical spending in the United States, 1960–2000. N Engl J Med 2006;355:920–7.
3 Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138:273–87.
4 Skinner JS, Staiger DO, Fisher ES. Is technological change in medicine always worth it? The case of acute myocardial infarction. Health Aff. 2006;25:w34–47.
5 Bloom BS, de Pouvourville N, Chhatre S, et al. Breast cancer treatment in clinical practice compared to best evidence and practice guidelines. Br J Cancer 2004;90:26–30.
To the Editor––Bryan Luce and colleagues [1] show that medical care starting from birth has yielded a return on investment (ROI) greater than one in the United States between 1980 and 2000. A major assumption of their analysis is the price of an undiscounted life-year, set at $100,000. The authors also present the ROI of medical care for major diseases (coronary heart disease following acute myocardial infarction, type 2 diabetes, stroke, and breast cancer) between the 1980s and the 1990s. Calculations are based on Medicare data, i.e., patients at the age of 65 years and above. The ROI for each of the four disease states has been again greater than one, for breast cancer even close to five. Finally, the authors present the ROI of major treatment innovations for the diseases within the past 25 years, based on a literature search for cost-effectiveness analyses (CEAs).
It is quite striking that except for breast cancer the ROI of major treatment innovations is far higher than the ROI of all medical care for the disease in question. In fact, for coronary heart disease, type 2 diabetes, and stroke, all major treatment innovations yield a higher ROI than total medical care starting from birth. This result is even more surprising given that ROI decreases with age [2] and over time [2], i.e., more recent innovations have on average a worse ROI than earlier innovations. As Medicare, of course, covers not only recent innovations but also long-established interventions (such as basic clinical examinations), I would have expected a worse ROI for recent innovations than for all medical care provided. An important reason for this inconsistency might be that CEAs of specific treatments do not incorporate the costs of overuse, i.e., they consider only appropriate care. Hence, the large discrepancy could point to substantial treatment overuse. This would indirectly confirm previous analyses showing that some US regions have about twofold higher Medicare expenditures without better outcomes [3,4].
Still, the question remains why there is apparently no such discrepancy for breast cancer treatment. Is there less overtreatment in breast cancer than in the other diseases? Overtreatment also occurs in breast cancer patients, but it seems mostly limited to mastectomy in early stage disease [5]. Perhaps physicians adhere stronger to treatment protocols when treating breast cancer patients.
The authors did an excellent job at presenting a very detailed picture on the ROI of US medical care. Still, I believe that the main conclusion of their analysis should not be that US medical care has been worth its investment, but that ROI could be much better.
––Afschin Gandjour, MD, PhD, Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany.
References
1 Luce BR, Mauskopf J, Sloan FA, et al. The return on investment in health care: from 1980 to 2000. Value Health 2006;9:146–56.
2 Cutler DM, Rosen AB, Vijan S. The value of medical spending in the United States, 1960–2000. N Engl J Med 2006;355:920–7.
3 Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138:273–87.
4 Skinner JS, Staiger DO, Fisher ES. Is technological change in medicine always worth it? The case of acute myocardial infarction. Health Aff. 2006;25:w34–47.
5 Bloom BS, de Pouvourville N, Chhatre S, et al. Breast cancer treatment in clinical practice compared to best evidence and practice guidelines. Br J Cancer 2004;90:26–30.
Authors