Over-Diagnosing & Disease Mongering Down Under

Stone the crows! It looks like we are spending more money on healthcare than we need or can afford. But don’t expect anybody to terminate the tests 

A large, long-term study of mammograms suggests they are not exactly value for money. A 20-year survey of 90,000 women in Canada found breast cancer killed women who had mammograms at around the same rate as those who didn’t. And 20 per cent of treated cancers found by mammograms were not a health threat.[i] It sounds like prostate cancer, which does not kill many of the elderly gents who have it – because old age gets them first.[ii]  In fact, the bloke who discovered the prostate specific antigen in 1970 has long argued against using it in routine testing.[iii]

And yet we test terrifically for both diseases. The Crows cannot find recent total costs for mammograms – a 2012 report cited $118 million per annum for mammograms, but that was a 2004-05 figure! However, in 2011 Medicare funded 354,000 tests.[iv] And two thirds of blokes aged 40-74 have had a prostate cancer test, which is on the Medicare schedule.[v] And a good thing too, says everybody who is alive or loves somebody who is, because of these tests.

But when the Feds kicked in a further $55m last year to extend the free breast cancer test to women aged between 70 and 74 program, Health Minister Tanya Plibersek said this would lead to the detection of 600 cases.[vi] Not cancers that will kill anybody mind, just cases.

We are doing this because we can – as technology improves doctors want to do everything possible to save lives, and avoid being sued. We also medicalise the human condition. Obesity is now a disease instead of a choice.[vii] A few years back drug companies attempted to create “inhibited desire disorder”, the names vary but you get the idea. This strikes the Crows as less a medical condition than caused by a lack of interest in sex or incompetent partners.[viii] And we decide people are sick when they feel fine.

According to Wendy Rogers from Macquarie University, “we seem to have lost connection with the idea of actually feeling ill”, pointing to people with raised blood sugar but who are fine. She adds, “To label them with a disease like diabetes, when they feel completely well, seems to run against our notions of what it means to be ill and need treatment.” [ix]

We are, in essence over diagnosing and disease mongering, which as Professor Rogers warns turns:

otherwise healthy and asymptomatic people into patients, by performing investigations, allocating diagnoses or providing treatments that do not improve patients’ health and may be detrimental. Through this looking glass, things are topsy-turvy: health care harms rather than heals; the well are made ill, and disease categories expand in alarming ways.[x]

But there is one genuine mental illness involved in all this – the delusion that we can afford ever more public health care spending. That the health budget will be bigger is inevitable, the nation is ageing and the old make more demands on the health system than the young. As the Productivity Commission points out, in 2010-11, people aged over 75 cost the Pharmaceutical Benefits Scheme 75 times the outlay on those under 18.[xi]

But expenditure is also increasing because everybody is consuming more.[xii] Demand, rather than industry inflation, is why outlays have increased by $40bn in a decade. John Daley suggests health spending will take up another two per cent of GDP in ten years.[xiii]

Given the purpose of medicine is to keep us alive and pain free, and given people tend to like living, we could spend the entire budget on health and it would not be enough. And to suggest we just tax and spend more misses the point. If health takes up an increasing share of GDP, something has to give – and the other driver of spending is welfare.

This confronts government with a cap C conundrum. To which the only, partial, solution is to triage spending growth.

There are an army of health economists who can do this. According to Lesley Russell, only three per cent of the 5700 items of the Medicare Benefits Schedule “have been formally evaluated for evidence of their efficacy and cost-effectiveness”.[xiv] Limiting elective surgery is less about any shortage of resources than the minimum levels of service the electorate will accept.

Certainly, controlling cost growth is possible. The Dutch have capped health spending by limiting 50 per cent of outlays to receipts from a hypothecated payroll tax. [xv]

Good-oh, but imagine how convenient this would be for premiers who could claim emergency queues were all because their state did not receive a fair share of tax revenues.

And there is also an army of opposition MPs, whichever side is in power, which will speak up for whatever patient group receives less of the increased expenditure. Consider the complaints if prostate tests or mammograms were dropped from Medicare on the grounds that the money could be better spent on other medical health services. And it would not just come from consumers. As Jim Gillespie, from the Menzies Centre for Health Policy puts it, “Every cut – or shift – in expenditure on health does not just affect patients. It also reduces the incomes of providers, whether doctors or pharmaceutical companies.

Governments setting out to control spending, or move it in more efficient directions, must have strong backbones.”[xvi] As well as supreme indifference to what happens at the next election. There may well be a case for reducing or abolishing altogether public funding of mammograms and prostate cancer tests on the grounds that scarce health dollars can save more lives on other programs.

But imagine the outrage if you did. As anybody who heard Linda Mottram’s ABC Radio 702 Thursday call-back segment on breast cancer testing already knows, it would be unforgiving, perhaps politically fatal.[xvii]

[i] Gina Kolata, “Vast study casts doubts on value of mammograms,” New York Times February 11

[ii] Samantha Donovan, “Older men unnecessarily tested for prostate cancer,” ABC Radio, AM November 16 2011@ http://goo.gl/eucWfO recovered on February 15

[iii] Melinda Beck, “Should men get PSA tests to screen for prostate cancer,” Wall Street Journal, February 14 2013

[iv] Australian Institute of Health and Welfare, Breast cancer in Australia: an overview (2012) 82, 108 @ http://goo.gl/Cqq8zy recovered on February 15

[v] Anna Salleh, “Taskforce recommends against PSA test,” ABC Science, May 22 2012 @ http://goo.gl/bMVQW recovered on February 15

[vi] ABC News, “Free breast cancer program gets budget boost, “ June 3 2013 @ http://goo.gl/9Z9Bq2 recovered on February 15

[vii] Andrew Pollack, “A.M.A recognises obesity as a disease,” New York Times, June 18 2013

[viii] Drake Bennett, “Drugs pushing women into a sexual arms race,” Sydney Morning Herald, May 29 2009

[ix] John Ross, “Christopher Pyne announces $500 million in research grants,” The Australian, November 8 2013

[x] Wendy A Rogers, “Avoiding the trap of over treatment,” Medical Education, 48 1 (January 2014) 12-14 @ http://goo.gl/8PJREu recovered on February 15

[xi] Productivity Commission, An ageing Australia: preparing for the future, November 2013, 11 @ http://goo.gl/cMxY3i recovered on February 15

[xii] John Daley, Budget pressures on Australian governments, 1 Grattan Institute, April 2012 @ http://goo.gl/PloEUb

[xiii] Daley, op cit 35

[xiv] Lesley Russell, “Medicare needs a decent check-up,” Sydney Morning Herald, February 10

[xv] Johannes Stoelwinder, “Sustaining universal healthcare in Australia: introducing dynamic efficiency,” (in) CEDA, Healthcare: reform or ration 24, April 2013 @ http://goo.gl/DorPNq recovered on February 15

[xvi] Jim Gillespie, “Securing Australia’s future: health care,” The Conversation, December 16 2013 @ http://goo.gl/j2OKsq recovered on February 15

[xvii] Matthew Bevan, “Voices of breast cancer,” 702 ABC Sydney February 13 @ http://goo.gl/fi5906 recovered on February 15