US healthcare is headed for disaster

Doctors want lower premiums and insurance to pay for crazy things; It can't happen

Three recent events tell us that US healthcare is doomed.  First, health care premiums have risen to new heights. Second, Medicare has agreed to pay for GRAIL cancer screening as part of coverage with evidence development and third, many doctors protested Cigna’s denial of coverage for a double lung transplant for stage IV lung cancer, leading the insurer to agree to cover it. How are these three things linked? Why does the combination mean we are doomed?

Health care premiums are rising

This week it was announced that health care premiums have risen to new heights, now totaling on average $24,000 a year for a family.  In the United States, we spend nearly 20% of GDP on health care. The next highest spender uses only half of that.  The average household income has remained stagnant for decades given that gains in income are entirely offset by health care spending.  As a result of this: do we live longer or better lives? No, much of the annual spending is on marginal or low value services. Many new technologies have no evidence of benefit.  American medicine is a massive financial regressive redistribution regimen, which occasionally results in the rare adverse event of improving human health.  Our life expectancy is falling.

For those of us who believe that universal health care remains a dream worthy of pursuit in America—and I am one of these people—we must be clear that universal health care can only be: things that work and are cost effective, and not anything you want—any whim or fancy.

Medicare covers GRAIL

GRAIL is a single blood test to screen for multiple cancers, typically solid organ tumors.  If the test is positive, it is entirely unclear what the optimum work up should be.  Probably it will involve a battery of imaging—perhaps repeated imaging—and may involve removing part of an organ if it is deemed to have a mass. We have no evidence that GRAIL testing will lower all cancer mortality. Nor, do we have evidence that GRAIL will improve all cause mortality. We don’t know all the side effects and harms of GRAIL, and downstream interventions.

Typically, we place the burden on manufacturers to show that their products improve health outcomes prior to sale. Manufacturers have to show benefits exceed harms. In the case of GRAIL, Medicare has made an exception. It will pay for the test for 50,000 people and use observational data to assess its benefit against controls. This means taxpayers will fund the confirmatory study (and a non-randomized one) instead of the company.  The decision by Medicare represents a fleecing of America.

Double lung transplant for stage IV lung cancer paid by insurance

In a prior Sensible Medicine post,

Should insurance companies pay for double lung transplants for stage IV lung cancer

I discussed the case of a woman with stage IV lung cancer (either extensive stage small cell or multifocal non-small cell lung cancer).  Vanderbilt doctors offered her a double lung transplant. This procedure has no convincing evidence, very likely has harms exceeding benefits, may shorten her life (as lung transplant is morbid), is extremely costly, and should not be funded by insurance companies, but rather grant and research funding.

Online protest led Cigna to cover the double lung transplant.  What is notable is that several doctors—most of whom lack knowledge about cancer—were quick to condemn the insurer and demand coverage.  Here are some examples.

Why medicine is doomed

American health care is doomed because there are no adults in the room.  If you see that you are spending more money than ever before—far more than peer nations—and not getting anything in return—the first thing you would do is ask: what spending might be wasteful or unnecessary?  Clearly, paying for an unproven cancer test would be top of the heap.  Why can’t GRAIL—with its multibillion dollar evaluation—pay for their own research?  Second, unproven solid organ transplants for cancer would be something that should be funded by research and not insurers.  Notably, no other developed country would consider a double lung transplant for stage IV lung cancer.  Yet, our administration is paying for GRAIL, and doctors on Twitter who know more about virtue signaling than cancer have pressured the insurer to cover this procedure.

American medicine is doomed because we want to pay for everything, and we want our premiums to fall. We want to have our cake and eat it too.  We are too ignorant to use evidence based medicine to adjudicate what procedures and tests to cover and which to abandon.

We are going to spend 25% and 30% of GDP on double lung transplants for metastatic lung cancer, and whole body MRIs for healthy 20 year olds; then we are going to spend 40% of GDP on sequencing everyone’s stools daily, and your annual PET CT.  At 50% of GDP on health care, we will give everyone a weekly pass to get unlimited, unnecessary radiologic imaging, and if two doctors on Twitter think you should get a solid organ transplant, insurers have to pay. 

They say that when Rome fell half the days in the capital were holidays. When half of US GDP is spent on health care, like Rome, the US will collapse—a society chanting “health care”, while diverting vast amounts of capital to fatten the coffers of for profit companies and predatory, not-for-profit hospitals, offering a polychromatic series of snake oils, while ignoring all the aspects of life that actual result in improved life expectancy.