Cheap But "Good Enough." Can We Accept Decrementally Cost Effective Interventions?

We can all easily agree that if something increases cost and offers worse outcomes (red in diagram), we shouldn't do it. That's why prescriptions for Vioxx and similar antiinflammatories cratered after reports emerged of higher cardiac mortality for these high-priced medicines that were only as effective as Advil.   We can also all agree that if something decreases cost and increases quality - we should do it (Green in chart)

The challenge is with the blue slice of these pie --medical services that increase quality (a little) and increase price (a lot).  That's true of a majority of novel interventions tested in the literature - they displace less expensive standbys, but offer some new advantage.  It's tough to say no for higher quality.

Another challenge, that is ill-studied, is an intervention that is less expensive, and not QUITE as good -but really "good enough," at least for most people (yellow in this diagram).  These decisions are clinically (and politically) difficult.

The early November Annals of Internal Medicine has a literature review on “decremental cost effectiveness” entitled “Much Cheaper, Almost as Good.”  Authors Nelson et al from Tufts Medical Center point out that in other industries we value products and services that are “good enough,” but cost much less. Examples include personal computers (not as good as mainframes), IKEA furniture (painful to assemble, but much less expensive), and the Nano automobile from Tata Motors (sacrificing comfort and safety but costing only about $2,000).  However, in health care, we only value the highest quality  - regardless of the price.  A good example of this was an NPR report this evening about MRIs.  They often cost $2000 in the US - and we have the best machines in the world. In Japan, the government-enforced price of an MRI is $120.  Is the best image worth this price differential?

The authors in the Annals article found 2128 cost effectiveness ratios in the medical literature between 2002-2007 – and only 33 involved sacrificing any quality for price. In general, these studies involved the sacrifice of between 8 hours and 1 week of quality adjusted life (0.001 – 0.021 QALYs), and the savings were beween $122 and almost $12,000 per patient.  (Of the studies they reviewed, only 9 were of high enough quality to fully evaluate).

Of course, in the majority of instances where there was an innovation that represented increased costs and increased quality, the “usual care” before the innovation might have been “decrementally cost effective.”

This is relevant to the firestorm over the US Preventive Services Task Force finding that evidence doesn't support recommending annual mammography for women under 50 (and only supports biannual mammography from 50-69).  This recommendation was NOT made to save money - but much of the vehement disagreement is focused on whether lives would be sacrificed to save dollars.  What if the number of "quality adjusted life minutes" saved by mammograms is less than the number of minutes women would spend getting additional mammography and having followup biopsies? Listening to some of the vitriol about this finding on the radio reminded me that we don't like to make tradeoffs, especially in decisions around our health.

We are unwilling to "settle" for a decrementally cost effective treatment for ourselves and our families and friends.  Further, the highest margins are often associated with newer, discretionary technology - so the medical system often does not discourage overuse.  This is the conundrum we face that makes technology continue to ratchet up the cost of health care.