We are told that Obamacare will save money by basing cost/benefit (rationing) decisions, made by centralized bureaucrats, using “evidence based medicine.” The idea—and it is all the rage—is that our ubiquitous medical studies will be able to show the cost controllers which procedures work best, and which least, which prophylactic medications work, and which don’t, etc.—so that money isn’t wasted by doctors and patients pursuing the wrong paths. Indeed, we hear that call from the highest places towers of Obamacare supporters—the more degrees the better—at places like the New England Journal of Medicine, which supports adopting a national QALY rationing system, too.
But what if the studies upon which these imposed criteria will be based are often wrong? (I’ve written here from time to time of contradictory studies). Now, a writer in Newsweek goes into some detail about how often medical studies point in the wrong direction. From the story by Sharon Begley:
First garlic lowers bad cholesterol, then—after more study—it doesn’t. Hormone replacement reduces the risk of heart disease in postmenopausal women, until a huge study finds that it doesn’t (and that it raises the risk of breast cancer to boot). Eating a big breakfast cuts your total daily calories, or not—as a study released last week finds. Yet even if biomedical research can be a fickle guide, we rely on it. But what if wrong answers aren’t the exception but the rule? More and more scholars who scrutinize health research are now making that claim. It isn’t just an individual study here and there that’s flawed, they charge. Instead, the very framework of medical investigation may be off-kilter, leading time and again to findings that are at best unproved and at worst dangerously wrong. The result is a system that leads patients and physicians astray—spurring often costly regimens that won’t help and may even harm you.
Begley points to a Stanford professor named John P.A. Ioannidis, the new chief of Stanford University’s Prevention Research Center, who has been exposing the many errors in the evidence, evidence we are supposed to rely on for coverage and care decisions:
This is Ioannidis’s moment. As medical costs hamper the economy and impede deficit-reduction efforts, policymakers and businesses are desperate to cut them without sacrificing sick people. One no-brainer solution is to use and pay for only treatments that work. But if Ioannidis is right, most biomedical studies are wrong. In just the last two months, two pillars of preventive medicine fell. A major study concluded there’s no good evidence that statins (drugs like Lipitor and Crestor) help people with no history of heart disease. The study, by the Cochrane Collaboration, a global consortium of biomedical experts, was based on an evaluation of 14 individual trials with 34,272 patients. Cost of statins: more than $20 billion per year, of which half may be unnecessary. (Pfizer, which makes Lipitor, responds in part that “managing cardiovascular disease risk factors is complicated”)...That made Ioannidis wonder, how many biomedical studies are wrong? His answer, in a 2005 paper: “the majority.” From clinical trials of new drugs to cutting-edge genetics, biomedical research is riddled with incorrect findings, he argued.
And yet, when a later study apparently found benefit to taking statins, there was a big push in the UK to have doctors prescribe the drugs for all adults over age 40 or 50 as a prophylactic to cut overall medical costs!
Some worry that learning the truth that medicine isn’t easily put into neat blocks will unleash the anti science zealots!
Ioannidis deployed an abstruse mathematical argument to prove this, which some critics have questioned. “I do agree that many claims are far more tenuous than is generally appreciated, but to ‘prove’ that most are false, in all areas of medicine, one needs a different statistical model and more empirical evidence than Ioannidis uses,” says biostatistician Steven Goodman of Johns Hopkins, who worries that the most-research-is-wrong claim “could promote an unhealthy skepticism about medical research, which is being used to fuel anti-science fervor.”
No, it just means that the scientists and media have to stop pretending that “the science has answered the question, now obey!”
The other week, I reported here and in my Weekly Standard warning about single payer health care rationing about a statement by the Wisconsin Medical Society. It urged prioritization, using medical studies to keep us patients from getting sick:
- Acknowledge that the goal is health rather than health services or health insurance
- Commit to a public process with structured public input
- Commit to meet budget constraints by modifying benefits rather than cutting people from coverage or reducing payments to levels below the cost of care
- Commit to use available resources to fund clinically effective treatments of conditions important to Wisconsinites.
But if Ioannidis is right—and even Goodman said many were tenuous,” if not wrong, that won’t work,” the “evidence based medicine” edifice currently being constructed to solve our cost/benefit conundrum is being built on sand.
Does that mean to pick up those cigarettes and start puffing away? Of course not. Does it mean doctors and patients shouldn’t weigh and balance the current state of medical knowledge in making treatment decisions? No. But it does mean a lot more humility is called for by our Obamacare would-be remake the health care system engineers about their ability to cut costs in this manner. And it certainly means we should not let faceless bureaucrats decide what doctors can and should provide based on “evidence” that is constantly shifting, is often ambiguous, and sometimes, flat-out wrong.
