Health reform skepticism, Part I

To the list of reasons Congress may find it difficult to rein in health-care costs, add "diagnostic creep." Step One: Society medicalizes imperfections that formerly were either not defined as disease or thought to be too minor and/or too intractable for treatment. Rambunctiousness becomes attention deficit disorder; impotence becomes erectile dysfunction; snoring becomes a symptom of sleep apnea. Step Two: Scientists discover treatments; government approves them; companies market them; physicians prescribe them; patients demand them. Step Three: Disease definitions expand to encompass more marginal cases and treatments and testing expand to deal with more nuanced symptoms. Ritalin gives way to time-released stimulants; Viagra gives way to Cialis; sleep apnea comes in three varieties, mild, moderate and severe, identified through millions of dollars worth of high-tech sleep studies. NPR's Alix Spiegel recently broadcast a fascinating piece about the campaign by Merck, the pharmaceutical giant, to expand use of its bone-strengthening drug Fosamax. The company's effort involved urging doctors to treat patients not only for osteoporosis but also for a milder form of bone loss known as osteopenia, which is common among middle-aged women. Encouraged by Merck, doctors began to think of it not as a natural aspect of aging but as a possible precursor to osteoporosis and fractures. Merck also helped doctors get bone-scan machines in their offices so that they could test women for osteoporosis and osteopenia. And the company lobbied Congress to get Medicare to reimburse for the tests. Alerted by their friends, women themselves began asking for the tests and the pills. Result: Medicare claims for screening exams rose from 77,000 in 1994 to more than 1.5 million in 1999, according to Spiegel's report, and Fosamax prescriptions soared. By November 2007, Fosamax was one of the 100 most frequently dispensed drugs in the U.S., with annual sales of about $1.7 billion. (A generic version became available in 2008, so the national Fosamax bill is now likely to decline.) Diagnostic creep sounds bad, but it obviously can be very good. Many children (and adults) have been helped by increased awareness of ADD and other previously unrecognized psychiatric conditions; drugs can indeed resolve their symptoms. Lord knows Viagra and its imitators have improved many lives. People who don't snore get better sleep; they're at diminished risk for conditions such as high blood pressure; they produce more at work; they are more alert behind the wheel. As Spiegel's balanced piece notes, Merck claims Fosamax helped many people prevent bone loss that could have led to even costlier problems. Who am I, or anyone else, for that matter, to draw the line between mere osteopenia and truly dangerous osteoporosis? But that's just the point. Health-care cost containment is all about line drawing, about separating the problems that are dangerous enough to warrant coverage from those that aren't. Americans have become accustomed to the opposite of line drawing. In large part because someone else -- insurance -- picks up a lot of the tab, they have been habituated to consuming more and more life-improving treatments. Indeed, they've come to feel entitled to do so. The health-care legislation being negotiated proposes measures to deal with spiraling costs -- including an excise tax on "Cadillac insurance plans" and a government panel to define what works best medically. I suppose those will have an impact. But to the extent they do, it can only be by pushing back against the public's sense of entitlement. Comparative-effectiveness studies can inform the discussion -- up to a point. We've already seen the blowback against one that suggested many mammograms are unnecessary or counterproductive. Is the government going to stop covering bone-density tests, much less tell women with osteopenia that insurance can't cover their Fosamax? I'll believe it when I see it.