November 1st, 2004

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Science
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Rationing Healthcare

I was recently reading an article in Walrus magazine (unfortunately, it’s not online) about the future of healthcare in Canada. The feature quotes Dr. Peter Ubel:

Doctors, he says, should check the price tag before ordering drugs and tests. Take fetal ultrasounds. “My wife had two thankfully normal pregnancies,” he tells the crowd at U of T. “Of course, we had ultrasounds done, even though no study has shown it does any good…With insurance, it’s a subsidized baby picture. [But] if we’d had to pay for it, I’d have said ‘Give me a DVD player.’

I had no idea about this–it’s a pretty enlightening article. Later Ubel goes on to explain that a PAP smear every three years is adequate to catch almost all potential cervical cancer cases. It costs $600,000 for each year of life saved for all the additional tests if it’s done annually. That’s too high a price for a human life, he argues.

Pages like this one make a case for having an ultrasound with every pregnancy, while this page says “the American College of Obstetricians and Gynecologists recommends ultrasound only when there’s a specific medical concern”. I’m not picking on ultrasounds here, but we’re clealy overspending on healthcase in a number of areas, and it’s going to have to change.

Consider these facts (all from the aforementioned Walrus article):

  • The proportion of Canadians aged 55 and over is expected to increase from 22% in 2001 to 32% in 2020.
  • People over 65 incur nearly half of all hospital expenses.
  • The cost of existing treatments keeps going up. The cost of cholesterol drugs is up 63% in one year, the proliferation of MRI machines has increased 61% in two years.

In light of our aging population and rising costs, we’re going to have to fix health care, or it’s going to stop being universal (such as it is) pretty soon.

Comments: 6 Responses so far

donna
November 1st, 2004
10:22 am

You know, part of me thinks “yeah, that’s fine, less useless tests” … but it’s hard to tell if it’s a useless test until AFTER the test has been done.

My grandmother, for example, was sent in for a “useless” x-ray. She was having a lot of back pain. Well, at 86, you’d expect someone to have some back pain. But, her doctor sent her in for an x-ray and it caught the fact that she was on the verge of having an aortic aneurysm and spent the next month in hospital getting major surgery.

On the other hand, I was having major, unexplained abdominal pain a few years ago, and was sent in for an ultrasound and they found nothing.

The doctor you quoted… well, I’m happy that he & his wife had two normal pregnancies. But what if they’d caught something? I bet his attitude would change.

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Darren
November 1st, 2004
10:44 am

See, I don’t think your grandma’s x-ray was useless. She had symptoms, so they recommended an x-ray. The point here is that statistically speaking, there’s very little value in doing ultrasounds on normal, healthy pregnancies. It’s a numbers game, and one we’ll have to be willing to play.

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donna
November 1st, 2004
12:33 pm

Darren: Part of the argument, however, is that what if you’re NOT having a healthy, normal pregnancy… and they don’t know it?

My other fear is that once you start getting into the “we’ll only give it if we need it” mindset, you’ll have (especially in the US) insurance companies balking at giving an ultrasound even if it IS needed.

I’d rather err on the side of caution, personally.

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Chris
November 1st, 2004
12:44 pm

According to the doctor in the article, the ultrasound wouldn’t really help if there were no other signs of problems:

“Of course, we had ultrasounds done, even though no study has shown it does any good.”

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Darren
November 1st, 2004
12:46 pm

Donna: This is Dr. Abel’s very point: no study has shown that ultrasounds are (in a statistically-significant way) effective in detecting abnormal pregnancies. Ultrasounds may find undetected abnormalities in a tiny minority of cases, but that does not necessarily justify the cost of offering ultrasounds to every pregnant mother in the country.

My point is that we have been erring on the side of caution. Currently, we can barely afford it. As the population ages, we will not be able to afford it. The nation already spends 10 cents on every dollar on healthcare. That proportion may have to grow considerably to accomodate the baby boomer’s generation, and I’m not sure that can happen.

You’re correct about American insurance companies. I’m purely discussing Canada’s socialized system.

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Andrea
November 1st, 2004
2:31 pm

Ultrasounds are not used primarily to screen for fetus abnormalities. One of the biggest benefits is that they can confirm gestational age. Without an ultrasound, doctors can only base your number of weeks on the date you had your last period. But that has very little to do with the date of conception, so, without an ultrasound, the gestational age can be out by two weeks. And that’s important because it affects when the woman needs to have a triple-serum test (for abnormality screening) and amnio. It also affects decisions about labour induction — if they let you go too long after your due date, you can end up with all sorts of tearing and need surgery, a longer hospital stay, and more after-care. Knowing the gestational age also affects the way physicians interpret other tests and scans.

They are used to diagnose and confirm pregnancy and to observe that the pregnancy is within the uterine cavity. This helps in diagnosing ectopic and molar pregnancies. They are used to check for vaginal bleeding to measure heart rate, both of which can relate to miscarriage.

During an ultrasound, the size of the fetus is also measured to help with diagnosing and managing poor growth.

During an ultrasound, they measure the crown-rump length, the diameter between the two sides of the head, femur length, and the circumference around the abdomen. Doctors can use this to calculate the weight of the fetus. Ultrasounds can also determine structural abnormalities before 20 weeks. This may affect the decisions about how to continue the pregnancy or planning for care after delivery. With an ultrasound, doctors can also check out the placenta’s position, which can affect both the mother and the fetus.

Ultrasound also lets you know if you have multiple pregnancies — there are lots of complications from twins, let alone quints.

The amount of amniotic fluid can also be measured to help diagnose other complications.

Knowing about multiple pregnancies or fetal abnormalities may not always translate into a direct health outcome. However, it does affect the doctor/patient’s ability to arrange for assistance, such as counselling, daycare for other children (if they figure the mother’s going to need bedrest for 2 months with twins), post-partum care, care for babies with special needs, or decisions to terminate. All of these can tie into financial and emotional issues, even though the pregnancy may not go better or lead to a healthier baby. There are all sorts of social costs to consider, especially in Canada, where the state picks up the bill for so many other things.

In Canada, you usually only get one ultrasound, unless there are reasons for the doctor to schedule more. In the US, where private insurance covers ultrasounds, a lot of people have a second or third ultrasound to find out the baby’s sex or just to feel better about things.

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