Value is Subjective
From my friend Ross Levatter, MD.
I’ve had several friends, both on Facebook and in real life, diagnosed with cancer over the last few years. And often it is higher stage cancer as it is typically true that symptoms often develop only after cancer has advanced or spread.
One method of picking up early cancer (or even pre-cancerous lesions in the breast and colon) is via screening. And yet screening is quite a controversial issue in medicine. Some people are concerned that it’s too expensive: in economics terms, that it doesn’t pass a cost-benefit test; that there are too many false positive and false negative work ups, leading to increased expense, unnecessary biopsies, undue patient worry, etc. Many well-respected medical statisticians and epidemiologists argue against almost all screening studies, whether they be via imaging (as in breast cancer screening with mammography) or invasive assessment (as with colonoscopy for colon cancer screening) or even simple blood tests (as with prostate cancer screening).
Given my knowledge of economics, such as it is [DRH note: it’s quite good], I’ve always held these statistical evaluations as somewhat dubious. That’s because value is subjective and determined by willingness to pay; yet virtually no cost-benefit analysis is done from the perspective of a paying patient (strictly, “customer,” because by definition screenings are performed only on asymptomatic people with no known disease.) The question instead is, “Should the government force insurers to cover this screening study for everyone, or for everyone in certain groups [e.g., women over 40 for mammography; smokers with more than a 40 pack-year smoking history for lung CT screens for early lung cancer] or is it too expensive for society?” No one explores: What happens when entrepreneurial physicians offer screening and those people who think it worth the cost, even with risk of false positive and false negative workups, etc. choose to get it done and pay for it themselves?
Because in our society screening is offered only en masse when the government decrees mandatory insurance coverage, doctors spend far more time lobbying Congress regarding the value of screening than advertising to individuals, whose values, after all should count way more than those of members of Congress, regarding the value of screening.
But there ARE screens available for many cancers, including the most common (breast, lung, colon, prostate.) Some radiology groups offer whole body screening with either CT or (without radiation) MRI. These can pick up not only cancers but also other problems like vascular aneurysms or stenoses. Each of us should consider whether the possibility of early cancer detection, even if we have to pay out of pocket, is worth it to us.
Ross is simply applying the main insight from the marginal revolution.
My own personal story. About a year ago, a friend died from a ruptured aortic aneurysm. A number of us, including Ross, were discussing it on Facebook. Ross pointed out that there are often no symptoms before it occurs, so when it occurs, it’s too late. He also noted that the test for an aortic aneurysm is straightforward and that if you have a problem, a surgeon can do something about it. (I told another friend who told me that a doctor acquaintance of his had been flying into Boston when he felt his aorta rupture, and that he knew right then that he would die, which he did.)
I sat with that knowledge for a few months and then arranged to see my doctor. I told her my concern. She asked if I had ever smoked. Answer: no. She asked if there was any history of it in my family, (I think she asked that.) Answer: no. Then she felt around and said she couldn’t detect any problem.
“If you want to proceed,” she said, “I can order the test, but your insurance might not cover it and it costs hundreds of dollars out of pocket.” “Fine,” I said. I got the test and my insurance company did cover it. I didn’t have a problem. But I’m still glad it did it and would have been glad even if I had paid the whole tab.