NIH Endorses Patient Power

Commentary by John C Goodman

A group of scientists made a pronouncement about mammograms the other day, and it's causing great consternation. After much study and deliberation a panel convened by the National Institutes of Health (NIH) said it could not recommend regular mammograms for women in their 40s. Instead, the panel said, women under 50 should decide for themselves if and when to have a mammogram.

The NIH declaration flys in the face of contradictory advice from the American Cancer Society and the American Medical Association. But it's not that unusual for doctors to disagree. Pick up any medical journal and you'll see lots of diversity of medical opinion. Nor is it unusual for people to make their own decisions in the face of conflicting advice on matters ranging from the value of vitamin C to the virtues of jogging.

So why so much commotion? Because the NIH decision poses a dramatic threat to three groups with significant stakes in the issue: government risk regulators, managed care bureaucrats and patients wedded to the idea that experts should make all their medical decisions.

Consider the problem of regulators. Over the past several decades, we have concocted an alphabet soup of regulatory bodies whose reason for being is the belief that individuals cannot possibly make rational decisions for themselves concerning life-threatening risks. If people cannot be trusted to make wise decisions about safety belts or air bags, how can they be trusted to choose whether or not to have a mammogram? Clearly there's a slippery slope problem here. Individualize mammogram decisions and pretty soon people will be wondering why we need OSHA or the FDA.

Then there is the managed care industry. HMOs were founded on the principle that individuals cannot and should not choose between health care and other uses of money. And this philosophy has gained an important foothold at the White House and on Capitol Hill. From Hillary Rodham Clinton to Senator Ted Kennedy, the main argument against medical savings accounts last year was that people can't possibly make good decisions about whether to buy medical services like mammograms.

The third group of concerned and affected parties deserves more sympathy. Some women worry that insurance companies, employers and HMOs will use the NIH decision as cover to declare mammograms "unnecessary" for the under-50 set and quit paying for them. No doubt they will. But that's not a reason to force scientists to change their minds. It's a reason to empower patients rather than third-party-payer bureaucracies.

Annual Mammogram

Before considering how to do that, let's take a closer look at the decision that has to be made. Based on a review of the academic literature, the 1995 Harvard Risk Assessment Project discovered that annual mammograms for women in their 50s cost about $110,000 for every year of life saved as a result of those tests. [See the diagram.] For women in their 40s, that number climbs to $190,000. (These figures include all costs, including the cost of giving the tests to women who prove healthy and treatment costs for those discovered to have cancer; but they ignore the potential to earn income.)

Economists have studied risk awareness by measuring how high wages have to be to induce people to take riskier jobs and by looking at other choices involving risk. According to these studies, people are willing to trade from $10,000 to $500,000 for a hypothetical year of life. The mammogram numbers above fall within this range. But among individuals, the variation in attitudes is even larger.

For example, if a woman stays awake at night worrying about breast cancer, it's probably not a bad idea to get a mammogram - the extra money is worth the peace of mind. On the other hand, for a woman who smokes and rides motorcycles without a helmet, skipping a few mammograms is consistent with her other behavior. These differences help make the case against one-size-fits-all bureaucratic decision making.

Another argument is that third-party bureaucrats always have biases different from our own. Suppose we had national health insurance, with government paying all medical bills. To a mercenary ruler, a few thousand dollars in extra taxes collected each year could hardly justify spending more than a hundred thousand on a test to save one year of life.

The Clinton administration isn't quite that mercenary. However, Hillary Clinton's decision to cover regular mammograms for women in their 50s, but not in their 40s, in the original Clinton health care plan implied an unwillingness to spend much more than $100,000 to save a year of life.

A similar standard drove the Clinton administration decision to cover pap smears for women every three years, rather than the annual test recommended by most doctors. According to the Harvard Risk Assessment Project, obtaining a cervical cancer test every year, rather than every other year, costs almost $1.5 million per year of life saved for women age 20. Clearly, the advice physicians have been giving is outside the range of risk preferences people normally express. On the other hand, a test every four years - rather than every three years - is a really good buy: less than $12,000 for every year of life saved.

Following the lead of the NIH, then, a strong case can be made for allowing patients to make their own decisions with respect to mammograms, pap smears and, indeed, almost every diagnostic test. But third-party insurance makes individual decision-making difficult: insurers' decisions about what services to cover apply to everyone in the insurance pool.

A solution to this problem is the medical savings account. Insurers could carve out domains where individual choice is appropriate and deposits funds to MSAs so that enrollees could pay for services they choose to purchase. Individual self-insurance through MSAs is the answer to the need for individualized decision-making in the face of the risk and uncertainty inherent in the medical marketplace.