Category Archives: Health Economics

Facts or persuasion in health care decisions?

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A thought-provoking perspective article in the NEJM 2012; 367: 1677-79 makes the argument that public health organizations/health professionals should be providing facts to inform people and not try to persuade or dissuade  them from screening for health conditions.

Examples of persuasion:

  • “The early warning signs of colon cancer: You feel great. You have a healthy appetite. You’re only 50.” (ad from New York Times Magazine from Memorial Sloan-Kettering Cancer Center)
  • “If you haven’t had a mammogram, you need more than your breasts examined.” (from American Cancer Society, 1970s)

The problem with persuasion messages is that they are ‘stripped of useful facts’ that indicate that screening can have harms as well as benefits.

For colon cancer, most 50-year-olds who feel great will not develop colon cancer.  The National Cancer Institute estimates that a 50-year-old has a 6 in 1000 chance of developing colon cancer in the next 10 years; the chance of death from colon cancer in that period 2 in 1000.  The advantages of colon screening would be to reduce that risk further: 67% with colonoscopy and 26% with sigmoidoscopy.  Screening, however, could result in bleeding, anesthetic complications, or perforation.

The tactics of persuasion rely on making people feel vulnerable and offering them hope.  Informed decisions allow appropriate expectations about the true benefits relative to harm.

Life in the balance (book)

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While a recent blog (“There is More to Life Than Death”) referred to the complexity of  population-based medical decisions when relying solely on mortality, clearly mortality matters a lot.  In the same NEJM issue, an article highlights the difference that expanded Medicaid coverage has on mortality in adults (NEJM 2012; 367: 1025).

Traditionally, Medicaid has covered only low-income children, parents, pregnant women, and disabled persons.  In the past decade, several states expanded coverage to include nondisabled adults without dependent children.  This study examined these efforts in three states (New York, Arizona & Maine).  Then, effects on mortality were examined from 1997-2007 in these states as well as bordering states who did not expand coverage.  This time period allowed data to be analyzed five years prior to change and five years afterwards.

Findings:

  • By broadening eligibility requirements, there was a 25% increase in Medicaid coverage.
  • States with Medicaid expansions reduced all-cause mortality by 19.6 deaths per 100,000 adults; this was a relative reduction of 6.1%.
  • Mortality reductions were greatest for older adults (35-64), nonwhites, and residents of poorer counties.
  • The authors note that these changes do not prove causality.  However, there are implications for the affordable care act which allows expansion of eligibility up to 138% of the federal poverty level.

Despite apparent improvement in mortality, the cost, logistics and politics of expanding medical coverage remain unclear. In Georgia, the decisions on expanding medical coverage are quite controversial (see links below). My view: I think everyone in this country needs at least basic medical coverage.  This saves lives.

Deal rejects expansion of Medicaid | www.ajc.com

Expand Medicaid? – Blogs – Atlanta Journal-Constitution