The Health Care Lottery

Below, a guest-post by Nortin M. Hadler, M.D., Professor of Medicine and Microbiology/Immunology at UNC Chapel Hill’s School of Medicine.Dr. Hadler is also an Attending Rheumatologist at UNC Hospitals, and author of The Last Well Person: How to stay well despite the health care systemWorried Sick, A prescription for health in an overtreated America and Stabbed in the Back, Confronting back pain in an overtreated society.

I don’t buy lottery tickets. True, someone will win, and likely a mind boggling windfall. That someone may be one in a million, but someone will win. It is so unlikely to be that someone, maybe there’s a magical force at play, maybe a gambler’s gryphon or a good fairy. Many reasonable Americans must believe in the gambler’s gryphon. Some have premonitions, a sense that the gryphon will fend for them in the deepest reaches of improbability where the power ball hides. None of this is irrational behavior. All understand the probabilities and many get a kick out of the possibilities.

Many states have deemed the purchase of lottery tickets legitimate if not moral, usually because some portion of the proceeds is to go to the common good…and someone wins. My choice not to play the lottery is simply my choice; it is not a reproach to those who play. However, the psychology of the lottery has been so well inculcated that it commonly makes sense to apply it to another challenging win-lose exercise, betting on our health. It drives the “I know the chance is slim, Doc, but let’s go for it” response when we or our loved ones are sick. It also drives our choice of a health insurance plan. In the case of the lottery, we know what we’re doing. In the case of winning good health, we are all too often bamboozled. Let me explain:

Fat Chance?

The decision to undergo treatment revolves around our understanding that meaningful benefit is a more likely outcome than an adverse effect of the treatment. That’s a rational basis for a clinical decision. Next, we weigh the value we ascribe to the benefit against our fear about harmful effects. If we felt desperate we might want the treatment even if the likelihood of benefit was quite remote, as long as we valued the possibility of benefit more than the specter of harm. That, too, is rational. It is informed medical decision making.

How are we to be informed? There are many inputs coming from our social network, the media, and marketing. There is often a physician on whose opinion we might rely simply because she is an authority figure – so called eminence based medicine. In the case of pharmaceuticals, most of us assume that the Food and Drug Administration has responsibility for assuring that there is scientific evidence for a degree of benefit that outstrips the scientific evidence regarding the likelihood of harm. In fact the Kefauver-Harris Amendment to the laws regulating the Food and Drug Administration in 1962 mandated the demonstration of such efficacy before pharmaceuticals could be licensed. If we or our physician wishes, summary statements of the science that swayed the FDA are available as are collections of complementary science. We can rest assured that every licensed drug has a degree of efficacy that is at least comparable to other drugs designed for the same purpose – and harmful effects that have been considered to be a small price to pay for the likelihood of benefit.

That’s where our lottery mentality gets us in trouble. We are made to understand what we might lose if we don’t take the drug, but seldom do we question how likely it is that we will gain something if we do.  We are lulled into the notion that someone is winning or the drug would not be licensed. Don’t you want to know how many people need to be treated to benefit one? And is the benefit important to that one person or does it seem trivial? Would you buy a lottery ticket if the jackpot was trivial? You’d be surprised how many drugs need to be taken by 100 people or more to benefit one person, and you’d be surprised at how often the benefit is not meaningful. For example, how rational is the decision to lower your cholesterol or your blood sugar if either is deemed “high”?

Treating high cholesterol: Let’s assume you are a perfectly well middle-aged man who learns that his cholesterol is above the level some committee defined as normal. Now you’re worried. You have a “risk factor” for heart disease, stroke and death before your time. Naturally you feel relieved that your doctor can pummel your cholesterol below the upper limits of normal if you take her favorite statin drug. Few can refuse. Even fewer pause to wonder whether the result of doing so is meaningful to them. It turns out that if I treat 100 men with a statin and 100 with a placebo, after 5 years 96 would be alive in both groups.  Of the 4 who died in each group, 2 died of a heart attack. I wonder if these men would be as worried by their “high cholesterol” if they knew that their risk of death was 2% in 5 years with or without treatment. Of the 96 still alive and taking a statin, 4 had survived a heart attack. Of the 96 still alive on placebo, 6 had survived a heart attack. So if 100 men swallow a statin every day for 5 years, 2 might be spared the experience of a non-fatal heart attack. That is a surprisingly meager “win” for swallowing 1,800 pills.

Here’s where the lottery mentality leads us astray. The odds of winning a lottery are orders of magnitude less than 2%, yet many go for the win and someone will win. But the 2% reduction in risk on a statin does not guarantee anyone will win. In a randomized controlled trial 2% is right on the cusp of unbelievably small. Such small differences often do not reproduce when the trial is repeated. That means you do almost as well on the placebo and maybe as well. That’s like winning the lottery without buying the ticket. When the effect size is very small on a randomized controlled drug trial, the thinking should not be “someone wins” but maybe I would win without the risks of taking the drug.

I won’t even let anyone check my cholesterol, or PSA for that matter. I never submit to screening unless the test is accurate, the disease is important, and something important can be done about it.

Treating high blood sugar: Oral hypoglycemics are prescribed to lower blood sugar in people whose blood sugar qualifies as “Type 2 diabetes”. All of these drugs lower the blood sugar or they would not have been licensed. So if I were to treat 100 people, I will lower the blood sugar (or its modern measure, Hemoglobin A1c) to some degree in all 100. The assumption on the part of the FDA was that this must be a good thing to do, an assumption that is widely held by physician and patient alike even today. I say even today, because the flaw in this reasoning was revealed by 3 long-term, large trials of lowering the blood sugar of people with Type 2 diabetes. Nothing meaningful was accomplished; no one was spared a heart attack, renal failure, stroke, amputation, death before their time, or any other of the feared outcomes associated with Type 2 diabetes . For some of the brands of oral hypoglycemics, there seems to be an increased incidence of these feared outcomes. In 40 years of practice, I’ve never prescribed an oral hypoglycemic drug. I’m waiting for the demonstration of meaningful benefit. I’m waiting for the FDA to demand as much.

I’m also waiting for a trial that shows that stents do something for my patients (such as spare them a heart attack, chest pain, death before their time) and not just do something to their coronary arteries. The three randomized controlled trials have all failed to show any meaningful benefit of stenting over medical treatment alone regardless of how quickly people are rushed to the stent-placer . And why don’t we ask if a cancer chemotherapy regimen or cancer surgery offers something meaningful. Sometimes there is a science in the affirmative. Often times the intervention might do something to the tumor such as shrink it but nothing meaningful for the patient. I would want to know that before signing the “permission” slip. And if a few of the treated patients happen to live longer, I would want to know my chances of being so lucky without the treatment.

Where is the Power Ball hiding?

It’s bad enough that Americans all too often are allowed (encouraged) to approach medical decisions with a lottery mentality.  We are also asked to choose the lottery we want to play in. Those of us who have health insurance generally choose our coverage from a menu of plan options. Those who have no health insurance will be faced with similar choices should any of the many proposals in Congress prove lawful. How do we choose?

The menu of possibilities includes varying co-pay choices, deductibles, coverage caps and choice of doctors. Rational choosing is nearly impossible. It’s a lottery. For example, if you are well you might be tempted
to go without insurance, or opt for the plan that entails the lowest payroll deduction, usually with a high deductible. If you stay well, you win. But should you require an appendectomy or surgery for the fracture you suffered playing sports you could very well be faced with over $10,000 in bills. You lose.
I understand that the citizenry of most states consider playing the state lottery a morally defensible exercise. Turning health care into a lottery is morally indefensible.

10 thoughts on “The Health Care Lottery

  1. Why are the odds of winning the same if the chance is slim or fat?
    The lottery mentality, imo, is based on optimism bias.
    While my chance of winning is small, my particular chance of winning is better than the average ticketholder.
    The same bias may apply in medical decision making.
    The reason that some rationing is appropriate is to bring more objectivity into the decision making.
    Asking a hurting patient to forego treatment, even if a long shot at improvement, is like asking an employee to forego a raise, for the benefit of the employee community.
    We need to start thinking more of winning and losing in a more expanded concept than individually.
    When it comes to life and death (and heaven and hell), asking one to be objective regarding his health care decisions or theology preferences is asking too much, imo.
    This is why the decisions take a team effort.
    Don Levit

  2. I have on occasion bought a lottery ticket. My yearly spending on the lottery probably hits $10.
    My yearly out of pocket for health insurance for that lottery is around $10,000. Ten thousand is way too much already, but if it increases to 20 or 30 grand I simply can not afford it.

  3. Dr. Hadler’s perspective is well worth noting as an antidote to the fallacious assumptions that often cause us to overestimate risks or benefits. I would quibble, however, with two statements he makes:
    “We can rest assured that every licensed drug has a degree of efficacy that is at least comparable to other drugs designed for the same purpose”
    For many types of drugs, the FDA only requires a demonstration of superiority to a placebo, rather than equivalence with other drugs. Demonstrating the latter is statistically demanding and is resisted by the pharmaceutical industry.
    I also have some concern about underestimating the value of interventions designed to benefit certain high risk groups. An example entails the use of statins in high risk individuals. The exact place for these drugs has yet to be established, but I expect that over the course of a lifetime, the benefits are likely to be substantial, even if the benefits quantified on an annual basis are not dramatic.
    Some evidence has recently been published in a meta-analysis by Brugts et al – “The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials.” BMJ. 338:b2376, 2009.
    Based on 10 studies involving 70,388 individuals, the authors concluded that “In patients without established cardiovascular disease but with cardiovascular risk factors, statin use was associated with significantly improved survival and large reductions in the risk of major cardiovascular events.”
    With a mean follow up of 4.1 years, statins were associated with a 12 percent reduction in all cause mortality, and even greater reductions in major cardiovascular events. The article should be visited for the quantitative details.

  4. Speaking of the lottery mentality in medical care, it’s in the insurance mentality, too.
    In any insurance, the insurer is betting that you are mistaken about the likelihood that you’re going to have an auto accident, your house will burn down, or. . . you will come down with some disease, etc.
    However, if you have a bad driving record, or have had a house or two burn down; or show any traces of illness, or overt illness likelihood, they will either raise the terms of your policy, or in pretty obvious cases, refuse to insure you at all. Or stop insuring you. YOU MAY BE RIGHT, and that means $$$ lost for them.
    Let’s stop thinking and talking about healthcare INSURANCE. We shouldn’t be gambling over the provision of healthcare. The very idea is morally repugnant!

  5. This article makes some very important points (if a bit extreme). We very rarely look at one of the most important statistics that can be reported in clinical trials: number needed to treat. This refers to how many people must be treated with a therapy to prevent one bad outcome (or to attain one good outcome). An even more often ignored statistic is number needed to harm; how many people who are treated will be harmed by the treatment.
    I would point out that oral hypoglycemics are beneficial for people with extremely poorly controlled diabetes. The benefits are less clear for those with mild diabetes, and the amount of money that is spent is not justified, especially when one takes into account adverse events (for instance, hospitalization due to low blood glucose).
    Dr Hadler also points out our willingness to accept proxy measures of improvement, rather than more concrete measures. For instance, a large study of simvastatin + ezetimibe (marketed as vytorin) showed that although LDL was decreased, growth of plaques in coronary arteries was either unchanged or *increased.* Considering that one of the major reasons for treating cholesterol is to prevent heart attacks, it’s hard to justify using this drug regimen. But billions of dollars were spent on this drug before we found out that there was likely no benefit. Of course, we still don’t have any data on effects of this drug on morbidity or mortality, which are the real things that matter, and this medication may yet prove to have some benefit. But the benefits are quite unclear at this point and certainly not worth spending billions of dollars on, when there are other things that we know can truly improve morbidity and mortality.
    Another problem we run into is that those patients who participate in clinical trials tend not to have other medical problems, whereas in the real world most people have more than one thing wrong with them. We often have no idea how well treatments work in typical, real-world populations.
    Overall, it’s time to start looking at outcomes that matter, and to spend our money wisely, rather than allowing pharmaceutical companies to dictate the care we provide.

  6. We ALL need to listen to Nortin Hadler
    But he is so advanced sadly neither he nor we will live to see his ideas be fully accepted/implementented
    But like most visionaries his seeds will flourish
    Dr. Rick Lippin
    Southampton Pa
    “Charter Hadlerian”

  7. Dr Rick,Sharon MD,Fred, Ed, Don
    Dr. Rick– I agree that Hadler is ahead of his time. The myths of modern medicine– our belief that ything can be cured– is a 20th century myth that goes back to the major medical breakthroughs that we saw in the middle of the century.
    Since then, medicine has been turned into a business filled with a great deal of hype.
    And of course our fear of death makes us want ot believe.
    They I suspect that at some point in the future we are going to realize tha to living to 110 is not what it is cracked up to be. Too many of us are going to outlive our minds, and as we see that happen to loved ones, we will come to realize that are worse things than dying.
    (I hate to be morbid, but I do think this will happen to my generation of boomers. And I don’t see much hope of finding a “cure” for Alzheimers.
    Sharon MD–
    You make an excellent point about “number needed to treat” and “number needed to harm.”
    People also need to re-examine accepting “proxy measures” as proof of efficacy.
    For a long time we thought that if a treatment caused a tumor to shrink, we were curing the cancer.
    And yes, clinical trials don’t necessarily mirror how a treatment will play out in the real world.
    Finally, and most importantly, we should not let drug-makers set priorities—as you say, we need to focus on outcomes that matter, not marginal benefits.
    I did quite a bit of work on statins a couple of years ago, writing a two-part post titled “The Cholesterol Con.”
    While I haven’t seen the BMJ study you refer to, up until now there has been very little evidence that statins are saving lives. For people over 65, in particular, the risks of side effects (deep muscle pain, even memory loss) outweigh benefits.
    And the evidence that high cholesterol leads to
    fatal heart disease is tenous.
    Over a period of decades everyone from Wesson Oil to the markers of satins have poured hundreds of millions into promoting the theory–and we still don’t have hard evidence.
    A doctor once prescribed statins for my husband. He took them for a few months, didn’t like they made him feel, and he stopped. That was years ago–and he still shows no signs of heart disease. . .
    When I wrote the cholesterol con, I expected to hear from my patients telling me that statins had saved their lives. Instead, I received an enormous number of e-mails from patients telling me about the side effects they experienced, and how much better they felt after they took themselves off statins. . .
    I’m not an MD, and as I say, I haven’t read the recent reserach you refer to in BMJ, but I am wary of the hype surrounding statins–and the overuse.
    We’re not looking at increases of $20 or $30 grand. Very few people could afford insurance at that price.
    Something has to give–that is why the governmetn is stepping in to reform healthcare, and is trying to tell us that we are going to have to cut back on unneeded tests and treatments and rein in health care inflation.
    For a long time, we’ve been using medical resrouces without really thinking. “What harm can it do — why not . ..”
    Now we know that many seemingly innocuous tests can do harm, and that we have been doing many unncessary surgeries (particularly heart procedures and orthopedic surgeries).
    People need to read Dr. Hadler’s books.
    Patients as well as doctors need to be more aware of the need to stop and ask– wait a minute, do I really need this? What are the possible risks?
    The people saying that premiums will rise $20,000 are trying to scare you about health reform.
    Health care will become much more expensive if we Don’t have reform.
    Experience shows that if we share decision-making with patients–and really level with them about risks as well as benefits–and the limit of benefits (this may give you an extra three months, but it won’t save you, and it may prolong the process of dying. . ) patients don’t always opt for more treatment.
    When it comes to elective surgery, after having the chance to mull over the pros and cons of a knee replacement 20% to 30% decide not to go ahead.
    Even when it comes to end-of-life situations, many patients would prefer to forego the extra three months if it means three months of pain and no hope of recovery. Palliative care specailists, who are trained to talk to patients about death and dying, can help the patient make the decision by being candid, and at the same time, making it clear tha the patietn does have options–and that the choice is his.
    Sometimes, famlies are much more eager to “do everything possible” while the patient himself (who will be enduring ‘everything possible’) may welcome the chance to think it over, and decide for himself.
    I can’t emphasize enough how important palliative care is. This is what refomrers had in mind when they talked about “end of life counseling.” The counselor’s role is not to decide for the patient, but to enable the patient to decide for himself by expressing his own greatest fears and hopes.
    For some people,living another 3 months is very important– there first grandchild is scheduled to be born in two months, and they want to be here for that. For other people, their greatest fear is too much pain or a complete loss of control over their body,and mind.
    All of these fears and hopes need to be addressed.

  8. The industry heavyweights President Obama neutralized through the summer are agitating that the health-care bills in Congress violate agreements they made with the White House, leave 25 million Americans uninsured and have the potential to increase medical costs.
    One day after Democrats celebrated the news that a bill drafted in the Senate Finance Committee would not increase the deficit, the prospects for speedy enactment of landmark reform grew murkier. Industry leaders, who have held their tongues for months, spoke in increasingly dire tones Thursday about the impact of the Democratic proposals, raising the specter of an eleventh-hour lobbying campaign to defeat Obama’s centerpiece domestic policy goal.

  9. Oh Maggie, I agree with you completely!!! Without reform, I do believe my health insurance will be twice as much in a few years. It is twice as much in the past few years without reform, so if nothing changes, the trand will continue.
    Frankly, threats from an “industry report” that my health insurance will rise are so transparent.
    If we gve them the opportunity though, they will find a way to keep enriching their corporations — that is what corporations do after all!!! I don’t really blame the people who work in the system, I think the system stinks instead.
    To reform healthcare we MUST change the “system” the people in healthcare are generally very good people.
    We must take the money out of medicine, otherwise, it remains the problem.