AG: High Prices in Massachusetts From Market Leverage

(Click image to enlarge)

Martha Coakley has been in the news mostly for her upset loss to Scott Brown in the special election to fill Ted Kennedy’s Senate seat.  Her office got only a little coverage  when it released its report on medical cost increases in Massachusetts last week.  The 27-page report makes for good reading for those interested in what drives high medical costs here in Massachusetts.

The AG’s office, using civil investigative demands, obtained payment information from 5 insurers and 15 provider organizations, and came to the following conclusions:

1)       Prices paid to different providers differed by a factor of more than two.
2)       Higher prices were not associated with
a.       Higher quality
b.       Sicker patients
c.       Portion of patients on Medicare and Medicaid
d.       Teaching status
e.       Hospital resource costs
3)       Higher prices were associated with market leverage
4)       Providers receiving global payment (capitation) were not less expensive than those being paid fee for service
5)       Most of the increase in cost in Massachusetts has been due to an increase in price per unit of service, not an increase in utilization.

Most of this is no surprise, and The Boston Globe did a series in Fall, 2008 demonstrating that payments are higher at Partners, Children's Hospital, and some other hospitals with reputational or geographic advantage.  The Globe actually identified institutions, while the AG’s office blinds all providers in this report.

Of course, in a free market – it makes sense for an organization with better reputation to get higher pay.  The market grants higher prices to Bose for headphones compared to Sony – and it’s OK to pay more for the same gallbladder surgery at Mass General compared to a community hospital.   But the amount of the difference has become staggering.  Worse still, the highly-paid institutions can afford to make investments that lead to more future business – while the lower-paid institutions skimp on capital investment, and continue to lose patients, leading to still higher costs.

What can be done to address this?

One option is the Maryland approach of regulating prices.  Price regulation is a blunt instrument –and generally cannot keep up with changes in technology.  We also see from the distortions in Medicare physician pricing that price regulation can lead to big winners and big losers.  In the US and across the world, price regulation also leads to shortages of services that are paid relatively poorly.

Another approach is to move to bundled or global payments.  However, Ellen Zane, CEO of Tufts Medical Center (which is one of the lower-paid academic medical centers in Massachusetts) pointed out at a Harvard Business School panel yesterday that capitation would likely lock in current high prices at the currently-advantaged institutions. 

A third approach is to give patients large deductibles, and count on them to do better comparison shopping when they have to pay their own dollars.   There is evidence that this works for less-expensive elective medical care. However, most  hospitalizations in Massachusetts are so expensive that most patients who have any inpatient stay at any hospital – even the most cost effective one – will hit the out-of-pocket maximum.

It’s distressing to see that this report suggests that global payment was not associated with lower overall costs.  There are only a few capitated groups included in this analysis – so perhaps the issue is a small sample size.  There is substantial evidence that fee for service leads to much higher utilization (and costs) than global payment.  Here’s some data on ophthalmology practice- showing that when fee for service ophthalmologists converted to a capitation payment (no incremental pay for extra cataract surgeries), their rate of cataract surgery plummeted (by half).  

The AG’s office promises detailed findings for hearings by the Dept of Health Care Finance and Policy that begin in mid-March.    The payment disparities are large – and they won’t be easy to change.

Health Care Reform will Change Innovation - Not Decrease It

I’ll be part of a panel at the Harvard Business School this weekend on the potential impact of health care reform on innovation and investment of private equity in health care.   I’ve heard a lot of concern and hand-wringing over whether managing health care costs would decrease life-saving innovation that nourishes the ‘knowledge economy’ of the US.  The worry is especially intense in Massachusetts, with our economy deeply dependent upon health care delivery, and pharmaceutical, medical device and basic science research.

While it seems that the brakes are on health care reform right now, I wanted to share my perspective on how health care reform and meaningful cost control could impact innovation.

First of all – the need to lower the rate of inflation in health care cost is real.  Medicare is a giant deficit-generating machine for the federal government. The Medicare trust fund will have a negative balance in just a few years, and states cannot afford rapid rates of increase in Medicaid costs. US manufacturers send their work overseas in part because of high US health care costs.  Many Americans are uninsured, and more are underinsured.   Americans have effectively gotten no real wage increases since 1988 while productivity has soared; this extra wealth has been used for health care expenses.

Things that are unsustainable don’t continue forever, and medical costs can’t continue to rise at a rate far higher than inflation.  If they do, they crowd out other meaningful uses for our resources.   A dollar wasted in health care could have been better deployed in education or in infrastructure investment – and either of these is likely to spur more innovation.

In the US, there have been examples of big disruptions in health care revenue – and these have not led to a decrease in innovation. Rather they have led to a change in innovation.

The transition of Medicare inpatient payments from a “cost plus” basis to a ‘diagnosis related group’ (DRG) payment method in the early 1980s led to dramatic changes and innovations in health care.  Under the “cost plus” system, hospitals were rewarded for capital investment that increased the cost basis – and there were cranes all over the country building new medical meccas to be funded by Medicare.   Under the DRG system, hospitals were paid a fixed fee for each hospitalization, and so they innovated to decrease lengths of stay.  The fruits of this transformation in hospital payment included minimally invasive surgery, ambulatory surgery centers, and home intravenous therapy for infections and other maladies that once required a hospitalization.  So – a decrease in health care payments led to system changes, and an opportunity to innovate that was different (but not less) than under the previous system.

Many other countries impose strict, even ominous, controls on prices.   This has many consequences – and sometimes leads to shortages. However, even draconian price control can lead to increased, not decreased, innovation.   In Japan, the government mandates prices, and lowers prices for services where volume increases sharply.  Japan has an even higher rate of MRI use than the US, and as a result, the “list price” of an MRI is under $100.  Have MRI manufacturers stopped innovating?  Hardly.  Toshiba has developed an MRI unit that is lower powered (less magnetic strength, lower resolution, less computing power) that can be purchased for under $200,000 – compared to multimillion dollar price tags for the most technologically advanced MRIs available in the US.  So  - the low prices didn’t lead to a decrease in innovation – but rather a change in innovation.

Here’s a graphic demonstrating four quadrants of “value” (cost vs. quality).   The upper right always increases value – costs are lower and quality is higher.  Public health interventions usually are in this quadrant, as are pediatric vaccines.   Not much else, I’m afraid – the medical delivery system was designed to improve lives, not to save money.  We can all agree that we want more innovations in the upper right quadrant. 

The lower left quadrant shows unequivocal value destruction – we spend more and get less quality. In retrospect, Vioxx is a good example of this – a medicine just as effective as Ibuprofen, dramatically more expensive, and associated with a substantial increased risk of heart attack.  We can all agree that we want to eliminate spending in the lower left quadrant.

The challenge is the other two quadrants.  Folotyn, a new chemotherapy medicine that costs $30,000 a month and shrinks tumors a bit over a quarter of the time but doesn’t increase life expectancy, is in the lower right quadrant (small increment in quality but large increase in cost).  That’s where innovation has focused in recent years – and that has not made the US health care system “higher value.”

I’d submit that meaningful health care reform (which will come sooner or later, because we can’t afford not to) will move interest and private equity investment into the upper left quadrant.  That’s the “disruptive innovation” quadrant – where we accept innovations like generic drugs and the Toshiba MRI machine that is decrementally cost-effective -  i.e. we get less quality, but the cost savings are dramatic.

In the US, we’re historically not very interested in ‘decrementally cost effective’ innovations.  I think that controlling health care cost inflation is likely to lead to more innovation like the lower quality MRI machine, and less innovation like a new $36,000 a year chemotherapy agent that is not associated with extending life.

I’m at peace with the upper left quadrant.

Salt Reduction and Cost Savings

(click on image to enlarge)
The New England Journal of Medicine published a computer simulation online late this week showing that salt reduction would reduce new onset of heart disease by 1/3 and stroke by almost half -- saving between $10 and $24 billion dollars of health care costs annually.

As we've seen, changes to the payment system are complicated and difficult to implement - since there is always a loser as we move to lower unit prices, or insist on more accountability from various parties in  the health care system.  Changes to the delivery system are even more difficult.

This is another example of a public health intervention being cost saving -not merely cost effective. The intervention is not free. Regulatory effort is necessary, since a large portion of the sodium in the American diet comes from processed food.  The authors estimate that salt reduction would yield between 200,000 and 400,000 QALYs annually - with cost saving as opposed to incremental costs.  The authors note that this is substantially better value than antihypertensive therapy for those with hypertension -which at between $6,000 and $26,000 per QALY is also a very good value!

We need to reform health care payment and health care delivery - but that seems further away today than last week.  Let's not forget the value of public health interventions as we contemplate making health care more affordable .  I'll be skipping salt from now on, too.

Baumol's Law: Will Health Care Costs Always Exceed Inflation?

David Herszenhorn has an interesting article in today's New York Times suggesting that it's not possible to get health care cost inflation below the general rate of inflation.  He interviews and quotes economist William Baumol, who wrote an article in 1966 pointing out that while many tasks got less expensive over time, others required similar labor input - and thus the cost did not decrease.

Baumol's academic studies were around performing arts.  A Mozart quintet took 5 musicians in the 1700s, and still takes 5 musicians today.  A flat screen TV is manufactured with far fewer inputs today than it was a few years ago -hence the cost comes way down.

Although Herszenhorn doesn't mention it, this relates directly to the CMS Actuary's contention that it requires flawed logic to assume we can lower Medicare fee increases to account for future 'productivity increases.'

I acknowledge that it's more difficult to reengineer health care delivery than to optimize a manufacturing process. It's not easy to get doctors to rethink their approach, and demands of patients facing loss of life or health are different than demands of consumers in Best Buy.   However, unlike the string quintet, there are elements of health care where input costs can be dramatically decreased.  Efforts at implementing Toyota production techniques at hospitals have dramatically decreased the number of steps required.  Most of us who have visited a physician office recently in the US and seen how many staff are required to do administrative (nonclinical) tasks know that there are substantial productivity gains possible in health.

Further, countries with robust growth tend to have large increases in health care costs, while countries undergoing economic contractions (think Russia after the fall of the Soviet Union, or Argentina after the currency failure) tend to have health care costs that go down.   Countries like Russia with declining health care costs, though, also often have far worse outcomes.  This would suggest that overall, health care costs are sensitive to the overall economy - lowering health care costs (or health care inflation) is difficult in good economic times, and easier in tough times.

I don't think Baumol's Law unequivocally tells us we can't manage health care costs.  It does provide insight into why it's so difficult.

Will Shaving a Half Trillion Dollars from Medicare Save Money?

It depends.

The Medicare cuts will certainly save the federal government money – that’s why the Senate and House health care reform bills cut the deficit over the next ten years.   However, whether they lower the overall cost of health care really depends on whether resource costs are diminished, or whether costs are just shifted from Medicare to other payers.

Here’s a graphic from Tom Bodenheimer seven years ago, showing that Medicare has been very effective at lowering rate of health care inflation – a contrast to the sustained high rate of inflation of private health insurance premiums .

 Full Text  (Requires subscription)

Here is the counterpoint, also a graphic from Health Affairs, showing the estimated cost shift from Medicare (and Medicaid) to private payers. 

 Full Text  (Requires subscription)

So – will the half trillion in Medicare cuts lead to cost shifting to other payers?

David McGuire, VP for Contracting at Partners, is quoted in today’s Boston Globe  that low Medicare rates are the cause of high prices for non-Medicare patients. 

The Medicare cuts (from a memo from the CMS Actuary)

- Medicare Advantage Plans ($201billion)
- Provider payment cuts – adjusting for productivity increases over time ($282 billion)
- Pharmaceutical cuts ($129 billion)

Medicare Advantage cuts will likely lead to lower enrollment in the private plans, and increases in premiums and cuts in benefits for some beneficiaries.  This is not likely to create much cost shifting.

Provider payment decreases could mean increased cost shifting to the private sector.  It’s likely that this will lead to some substantial efforts to lower the cost of care delivery.  Note also that some provider fee cuts might just not happen.  The AMA has successfully pressed for reversal of physician fee cuts each year, and hospitals are now complaining that their agreed-to lower increases were contingent upon a more substantial decrease in the uninsured than would be accomplished under the current Senate bill.

Pharmaceutical cuts  are likely to lead to higher utilization – so overall costs might not decrease.  Assuming that the higher utilization is for cost-effective medications, we could be purchasing high value from the increased drug spend (but we probably won’t save money).

Health care cost increases are complex and multifactorial.    Large Medicare cuts could lead to higher value from health care delivery – but are not likely to lead to dollar-for-dollar decreases in overall health care costs.

CMS: 2008 Medical Inflation Much Lower

The Centers for Medicare and Medicaid studies released its report on health care spending in 2008 – published in Health Affairs on Monday and covered extensively in the press.   The good news is that health care inflation overall was lower than it’s been for years (4.4%).  The bad news is that health care inflation continued to outpace growth in the economy – so health care moved from 15.9% to 16.2% of GDP. 

Some of the conclusions that have been widely reported 
- Health care is not immune to the effects of severe recessions
- Hospital inflation decreased to 4.5% - and hospital prices only went up 3%
- Physician services increased by 5% - the slowest rate since 1996.  Medicare physician spending, however, increased by 7.8%
- Prescription drug spending increased only 3.2% - continuing a trend of relatively low pharmaceutical inflation with the onset of many new generics and without big blockbusters coming out of the pipeline. Still, most of this increase was price (2.5%) as opposed to utilization.
-Medicare spending was up 8.6% - and growth in Medicare Advantage plans played a role.  Big cuts in Medicare Advantage reimbursement in health care reform could now have an impact on more constituents.
- Medicaid spending increased.

One observation that has not been covered extensively.  The government pays much lower rates (especially Medicaid). Therefore, a shift of a patient from commercial health insurance plans to Medicaid could  easily mean a decline of 50% in reimbursement to many hospitals.  If providers shift these costs by charging private insurers more, then there are no “real” savings.  On the other hand, if providers see decreases in revenue and reengineer their processes to allow for sustainability at lower reimbursement, then the increased government role should lower unit prices.

I’ve often blogged about the problem we have with unit price in the United States.  The CMS article has a great graphic (below) showing the role that price inflation (compared to utilization inflation) has played over the last 30 years.

 (click the image to enlarge it)

Our quest for certainty makes health care expensive AND exposes us to excess risk.

We intuitively believe that medical diagnostic tests are more likely to banish uncertainty than they really are.

Here’s an example. Many executives have an “executive physical” that includes an exercise stress test to be sure they don’t have coronary artery disease, and many patients pay to have a CT scan to assess coronary artery calcification.

Take a 45 year old executive with a normal blood pressure and a normal cholesterol – his “pretest” probability of having a heart attack or cardiac death in the next 10 years is about 1%.  Here is a link that lets you put in age, gender, blood pressure and cholesterol and calculates risk based on data from the Framingham data.

Imagine 1000 such executives, each with a 1% chance of coronary disease. That means that ten of them will have a heart attack or cardiac death in the next ten years.   If they all had exercise stress tests, with a 70% sensitivity (chance a person with disease will have a positive) and a 90% specificity (chance a positive is a “true” positive” we would have 107 positives – but only 7 of them would be correct.  The overwhelming majority of positive tests would be false positives.   There would be almost 900 negatives, and of these only 3 would be “false” negatives.  


This calculation of “posterior probability” is called Bayes Theorem

So – even with a positive test a patient has a low chance of serious cardiac event.  A negative test is much more reliable. However, the executive had a 1% chance of heart disease before the test, while after the test the probability remains about 1/3 as high. 

So – we have more data – but not much more information.  Here is a graphic way to look at this:

Worst of all, there is not evidence that people with no symptoms benefit from invasive therapy to correct cardiac disease.  Even the “lucky” executive whose hidden cardiac disease is discovered through this testing might not be so lucky either!

We desire more information – and insist on more diagnostic tests in a vain effort to banish uncertainty.  Alas, tests done under the wrong circumstances don’t do much to diminish uncertainty.  We want exercise stress tests, mammograms and prostate specific antigen tests, even when our risk of disease is low.  The “cascade” of follow-up tests costs substantial sums (the point of this blog).   This cascade also causes discomfort and anxiety –and sometimes real damage to patients.  


Observations on Managing Health Care Costs (Part 2 of 2)

This is a two part post.  Click here for part one of this post.

Observation Nine: We often promote competition that does not generate new value for patients, and reject competition that could create such new value.
Michael Porter (Redefining Health Care) has argued convincingly that we are encouraging competition and choice where it’s not meaningful, such as comparing quality scores for health plans, while we are not encouraging competition where it is more meaningful – such as quality scores for provider organizations.  Clay Christensen (The Innovator’s Prescription) points out that we need disruptive innovation to get to a $98 MRI like they have in Japan – but we have a series of rule that discourage innovations that are inferior but have a huge cost advantage.

Observation Ten: We medicalize conditions, driving up costs
From chronic insomnia to erectile dysfunction to attention deficit disorder, we have expanded the reach of medical diagnoses. In so doing, we have created huge additional health care costs.

Observation Eleven: While many see a primary care shortage, there is also a specialist glut
If we simply increase the supply of primary care physicians, but the supply of specialists remains high, it’s likely that our costs will increase.  That’s what happened in Seattle when Group Health created a “medical home” at one of its clinics

Observation Twelve: We are reluctant to regulate prices (and when we do, we design such regulation poorly)
Most countries regulate health care prices.  In the US, one state has continued to regulate hospital prices – and reports less cost inflation than other states  Many states gave up on price regulation when they found themselves unable to keep up with medical progressPrice regulation is messy, and there are some bad consequences. For instance, while I have already mentioned the $98 Japanese MRI, countries like Japan which regulate prices often standardize prices too low – so office visits there are reimbursed at under $25 – and physicians often see 100 patients a day.  Uwe Reinhardt describes hospital prices as "chaos under a veil of secrecy."  It's not clear we could make prices sensible by regulating them - and it's pretty clear that prices are not sensible now. 

Observation Thirteen: Providers must consolidate to allow for more integrated payment; however, provider consolidation increases the cost per unit
Tom Lee and Jim Mongan of Partners and others have made a convincing case that we need more integration of the health care delivery system.  Unfortunately, higher levels of integration often lead to higher unit costs – exacerbating our cost per unit problem.  The Boston Globe had a series demonstrating the high prices paid to Partners in Boston, and the Wall Street Journal did a great article on the increase in cost of health care in Roanoke Virginia after the two major nonprofits there merged.

Observation Fourteen: We often mistakenly think that we can measure the
cost of health care by medical claims alone
The health care system was not designed to “save money.” It was designed to make lives better (and longer.)  So – when an intervention costs real dollars, but gives a patient the gift of better health – that’s not bad.  We should measure the value of health care by what we’re getting out of it, not by the resources we're putting in.  If we can increase our productive lives, that’s of enormous value to us as patients, our families, our employers, and society as a whole.   It would be a terrible bargain if we spent 30% less on health care but didn’t benefit from minimally invasive surgery, or drugs that make AIDS a chronic disease, or drugs that actually decrease coronary artery disease.  

Observation Fifteen: Every health care dollar is someone’s income
Hospitals are the major employer in almost every community that has a hospital, and pharmaceutical companies, medical device companies, insurers and physician practices all are engines of employment and are dependent on revenue from heath care services. If we decreased the cost of health care by 30% tomorrow, we would see layoffs of hundreds of thousands – creating Detroits in virtually every community in the country.  We shouldn’t waste money in health care – but we shouldn’t expect to wean ourselves off of excess expenditures quickly (especially not in the current economic environment.)

Observation Sixteen: There are no magic bullets
Beware of the pundit who has an answer.   We’ll need to try multiple approaches to get more value out of health care.  This will require changes in health care delivery, changes in health care finance, and changes in public health efforts and investments.  Managing health care costs is not easy – note that virtually every industrialized country has seen health care inflation exceed general inflation over the past decade.  Managing health care costs won’t happen quickly.  There is likely to be reason to write this blog for a long time to come.  

Rush Limbaugh Endorses Health Reform

Not really.

But he did note, upon his discharge from a hospital in Hawaii where he was evaluated for chest pain, that he got the best health treatment in the world “right here in the United States of America.” 

Actually, Rush Limbaugh got his care in a very unusual state indeed. Hawaii is second in the Commonwealth Fund’s ranking of the 50 states (and the District of Columbia.)

Hawaii is different than the rest of the United States.  It has great weather, is geographically isolated, and has never had much heavy industry.  It also has an unusual health care system - one that has many elements that are similar to those being proposed as part of national health care reform.

 Here are some of the unusual elements of health care in Hawaii.

1) Hawaii was the first state to enact an employer mandate in 1974 - and has one of the lowest rates of uninsured in the country. 

2) Hawaii has expanded Medicaid eligibility substantially. Again, this lowers the rate of the uninsured

3) There are two dominant nonprofit insurers in Hawaii, The Hawaii Medical Service Association (HMSA--a Blue Cross plan) and Kaiser Permanente. The employer mandate explicitly requires coverage at least as generous as those plans offered by HMSA and Kaiser – just as proposed national health care reform would mandate minimum credible coverage.

4) Kaiser Permanente cares for 20 % of the nonelderly population of Hawaii.  This salaried, integrated staff-model health plan has a world class electronic medical record system, which facilitates collaboration among its primary care physicians and specialists.  Regions with large penetration of Kaiser tend to have low costs (compare the costs in San Francisco with those in Los Angeles, for example)

5) Hawaii regulates its health plans strictly, prohibiting excessive or discriminatory rates, and allowing the insurance commissioner to wide latitude to impose financial penalties on health plans that violate its regulations.

6) Hawaii has among the lowest Medicare costs in the country (but very high overall quality).  I'm attaching a graphic from Health Affairs (researchers from Dartmouth and now HSPH) showing this.

So, with an endorsement of the health care system of Hawaii – Rush is in favor of many of the elements of the Senate health care reform bill that he has railed against.

(I couldn't resist posting on Limbaugh's comments.  I'll be posting part 2 of my New Year's observations tomorrow)

Observations on Managing Health Care Costs (Part 1 of 2)

Happy New Year.

I’ve just finished my first full year of blogging about managing health care costs, and just completed my sixth year of teaching a course “Managing Health Care Costs” at the Harvard School of Public Health.  I wanted to share some observations from our final class of 2009.  Class slides are at this URL.  

This posting will be in two parts – I’ll post the second part tomorrow.

Observation One: Sick people are expensive to care for.
 The top 1% of nonelderly patients represent 30% of all medical costs.  We need programs to better manage those with serious illness, and a regulatory framework to discourage risk shifting and patient dumping.
Observation Two: The problem in the US is much more unit cost than utilization
In the US, we have fewer doctor’s visits, fewer prescriptions, fewer (and shorter) hospitalizations compared to all other developed countries.  But our average hospitalization costs over $12,000, compared to under $10,000 (France, Canada) and under $4000 (UK and Netherlands).
In Japan, MRIs cost under $100, compared to $1500 in the US
Observation Three: Our lifestyles cause large medical costs
The good news is that we smoke less than we did. The bad news is that we’re getting more and more overweight. 
Observation Four: We don’t like to make tradeoffs
Everyone agrees we should perform more care that increases quality while lowering cost.  This means we should give more vaccinations –but there aren’t many money-saving medical interventions. We also agree that we should do fewer things that raise cost while lowering quality.  So let’s not give middle aged men Vioxx, which works as well as ibuprofen but increases the risk of heart attack.  The challenge is that we are not willing to give up tiny quality increases at enormous costs. See, for instance, a new cancer drug that for $36,000 a month decreases tumor size in under 1/3 of patients.   We’re also reluctant to design systems that  are 'decrementally cost effective.'   
Observation Five: There is huge variation
Atul Gawande’s “The Cost Conundrum” in the June 1 New Yorker   brought well-deserved attention to the work of Jack Wennberg, Elliot Fisher, and others at Dartmouth who have been showing us the vast variations in utilization of health care.  In expensive areas, we have too many hospital beds and too many doctors – and we use them.  Good example of how decreasing hospital beds does not decrease quality in David Leonhardt’s column in the New York Times this past week. 
Observation Six: Fee for service is toxic
Imagine if we paid auto manufacturers by the bolt rather than for a completed car. We would have cars chock full of bolts –each one an extra cost, extra weight, and an extra ‘point of failure.’  That’s what we’ve got in a fee for service health care system 
Observation Seven: There is a cultural clash between those seeking to preserve the “art” of medicine, and those looking to create more reliability and cost effectiveness through industrial redesign
Jerome Groopman worries that electronic medical records and standardization will take the personal relationship out of medicine.  I worry that lack of accountability and standardization is responsible for many medical errors –and we just can’t rely on the extraordinary effort of individual physicians to insure quality and cost-effectiveness.
Observation Eight: We pay a heavy economic and noneconomic price in our effort to banish uncertainty
It’s our intuition that every additional piece of data increases our knowledge.  This is simply not true. We often gather data in our quest to banish uncertainty, and that data doesn’t much change the chance of real, serious, treatable disease, but does increase cost and increase the risk that we’ll do further, more dangerous tests or interventions. I’ll be blogging more on the vain quest for certainty in the coming days. 

I'll post Part II of these thoughts tomorrow.
[Addendum: thanks to Wellescent Health Blog for note, and I have finished the sentence in observation four]

Part Two of this post is here.