At Work With the CDC

Why it's so hard to agree on health care

Expert analysis of a debate on cancer screening reveals 63 permutations on points of view. Is it any wonder, then, that the nation has trouble achieving consensus on health care policy?

By Karen Resha

Since the late 1990s, the issue of routine mammograms for women under age 50 has been hotly debated. Some argue that the risk of premature death due to breast cancer is unacceptably high for this group. Others counter that the benefit is small at best, and the risk of physical and emotional scarring from false positive results and unnecessary invasive procedures is too high. The mammography controversy was distilled at a 1997 National Institutes of Health (NIH) consensus conference, and the mechanics of that debate illustrate the complex process by which health care decisions are made.

The process was analyzed by two former staffers of the Division of Cancer Prevention and Control of the Centers for Disease Control and Prevention (CDC). Edward C. Mansley, PhD, of the Outcomes Research and Management group at Merck and Co., Inc., and Matthew T. McKenna, MD, of the National Center for HIV, STD and TB Prevention at the CDC published the Importance of perspective in economic analyses of cancer screening decisions in the prestigious British medical journal The Lancet (Volume 358, October 6, 2001).

Mansley and McKenna suggested that each participant in the NIH consensus conference came to a personal decision after considering, from his or her own perspective, the potential "costs" (negative outcomes) and "benefits" (positive outcomes). The participants performed, in effect, an economic analysis of the preventive service, and their individual perspectives greatly influenced the costs and benefits that each considered. The authors suggested that it may have been this variation in perspectives, rather than differences of fact, that fueled the debate among conference participants.

Adding to the complexity of the debate is the sheer number of stakeholders. The patient, of course, is at the very center, but each patient probably has a family and an employer with legitimate interest in the costs and benefits of routine screening. On the clinical side, primary care physicians and specialists have different priorities. Private and public insurers will pay for the screening and for the cost of treatment at whatever stage cancer is detected. The health care system, including health policy makers, will have one perspective, while society as a whole may have another. That adds up to nine different viewpoints.

Mansley and McKenna presented seven components of the perspective that an individual brings to the economic analyses of cancer screening — or, for that matter, any other health care decision.

The first of these, the focus or primary concern of the decision maker, has two parts. Is the decision maker primarily focused on an individual patient (and family), a group of individuals or an organization? And second, is the decision maker mainly interested in maximizing health or welfare? Welfare — the overall sense of well-being of an individual, population or organization — is positively related to health, but health is not the only thing that affects welfare. The authors suggest that if the emphasis is on health instead of overall welfare, the decision maker may discount the effects of the screening process that are unrelated to health but are, nevertheless, important to patient and family.

For example, a physician is typically focused on the health of the patient, whereas the patient can be equally concerned about non-health issues such as lost time from work and the discomfort associated with the screening procedure. An employer may be concerned with an employee's health and the loss of work time/productivity, but not with the actual discomfort associated with the examination. The authors also suggest that when the focus is on an individual — rather than a population — potential negative side effects of the screening process are likely to be ignored or discounted because the probability of their occurring is small for a single patient.

There are wide variations in the second and third components of a decision maker's perspective: knowledge of the potential outcomes of the disease and knowledge of potential side effects of screening, diagnosis and treatment (including their probabilities). Health professionals typically know more about possible outcomes associated with screening (e.g., perforation during a colonoscopy), diagnosis (e.g., the likelihood that a detected tumor will cause death), and treatment (e.g., potential side effects like incontinence and impotence) than the patient, the patient's family and the employer.

Prostate cancer screening is one example where knowledgeable health professionals who take a broad societal perspective of population welfare are less inclined to recommend routine screening than a patient or physician. They argue that one cost of routine prostate cancer screening would be the numerous patients who develop incontinence and impotence from treatment of tumors that may never have threatened their lives.

The fourth component of perspective, the decision maker's knowledge of patient preferences and values, is essential to determine how patient welfare will be affected. Patients and their families obviously have the advantage here. Because individuals vary so tremendously, patients who face identical outcomes (e.g., the discomfort of a colonoscopy) may make different decisions about a screening test. Policy makers who must decide to screen or not to screen entire populations with the hope of maximizing welfare are likely to feel ill-equipped because they have little information about individual preferences.

Components five and six — the burden that the decision maker assumes regarding health impact and resource costs — have similar effects. For cancer screening, the potential health impacts generally fall on the patient and family, whereas most of the burden of resource costs falls on the insurer, health care system and society. Unless they operate in a capitated payment environment, physicians generally assume little burden for either health outcomes or resource costs. This may partially explain their tendency to advocate cancer screening and other types of health care interventions more frequently than insurers, government health agencies and public health professionals

The decision maker's time preference with respect to future benefits and costs is the seventh and final component of perspective. Individuals and private organizations tend to focus on short-term outcomes and typically discount or ignore outcomes that occur far into the future. For example, a private insurer may not place a high value on screening if benefits are not realized for 10 to 15 years. And patients themselves may not value the long-term benefits enough to incur the immediate "costs" of screening (e.g., inconvenience, discomfort, time, financial cost). Decision makers with a broad societal perspective may value future benefits more highly and thus be more inclined to opt for screening.

Mansley and McKenna focused on a single area of health care — cancer screening — but their work demonstrates the complexity of any health care decision on a personal or policy level. It also suggests that the ability to appreciate the varied perspectives of multiple stakeholders is a crucial factor in any fruitful debate.

Karen Resha is Health Communications Specialist, Office of Program and Policy Information, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.

Be sure to check out previous "At Work With the CDC" columns in our archive.

More Business & Health Articles on Cancer:

Breast Cancer: Early Detection Needed (October 2001)

Screening is Key to Preventing Colorectal Cancer (June 2001)

How Breast Cancer can Affect Your Workforce (Breast Cancer Sept. Supplement)

Cancer Resources for Your Work Site

Importance of perspective in economic analyses of cancer screening decisions from The Lancethttp://www.thelancet.com/journal/vol/iss/full/llan.358.9288.editorial_and_review.17870.1
(NOTE: You must first register for free on The Lancet web site in order to access this article.)

American Cancer Societyhttp://www.cancer.org/

Centers for Diseases Control and Preventionhttp://www.cdc.gov/cancer/

Cancer Carehttp://www.cancercare.org/

National Cancer Institutehttp://cancer.gov/

Karen Resha. At Work With the CDC: Why it’s so hard to agree on health care.

Business and Health

2002;10.