This cost-benefit trade-off surprises me, even in the context of health reform. The general understanding of comparative effectiveness decision making is that treatments that reduce costs are preferred—assuming they provide the same or a better benefit. The new guidelines would change that equation, upsetting existing practice and accepting a scientifically predictable loss of lives. We're talking about human lives here, not pork bellies.
What's the evidence that lives are at stake? Consider some of the task force's computer-generated comparisons of the mammogram-lite and mammogram-rich approaches. The most extreme model, produced jointly by the University of Wisconsin and Harvard, shows that the new guidelines would bring a mortality reduction (compared with women who have no screening) of 28 percent; the one that starts screening yearly at age 40 would amount to a 54 percent reduction. If one looks at the number of years of life gained—which is greater when younger women's lives are saved—the task force's approach brings 95 extra years per 1,000 women, far below the 202 years gained with the more intense screening schedule. Boiled down to its essence, curbing women's appetite for, or access to, mammograms could easily mean that more than 100,000 women would be absent from the ranks of the 2.5 million breast-cancer survivors. That's roughly two Vietnams or more than 30 9/11s.
This decision of the task force, while based on science, was in the final analysis a judgment call: the collective wisdom of 16 people presented with a range of reasonable options and no doubt influenced by their view of what's best for society as a whole. The call would easily be otherwise among 16 other experts—equally well schooled and presented with the exact same science—whose goal is primarily to maximize the number of lives saved. Unless there is a special act of Congress, as we saw in the Senate last week when Sen. Barbara Mikulski's health reform amendment was passed to ensure women reimbursement for mammograms prescribed by their doctors, choosing one set of guidelines over the other will mean less or no reimbursement for the guidelines not chosen—even if one is current practice.
These types of decisions, and the many others that lie ahead, demand that the full story be told, and explicitly: the science, the choices, the judgments and opinions, and, why not, the emotional dimension that must always be considered when human life is at stake. When there are legitimate differences of opinion on widespread medical practices and more than one scientifically based approach to care, it would seem unfair for the government to effectively begin rationing treatment by favoring just one.
[Read more about how health reform could mean the government dictating care.]