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Over-treatment of prostate cancer shows the cost of fee for service medicine: Gavin Mooney

Professor Gavin Mooney, health economist, writes:

Just 10 days after my Crikey article expressing concern about the lack of information I received from urologists about the probabilities of various outcomes following a raised PSA level for testing for prostatic cancer, lo and behold I have the information!

And it is good news for me – and not so good news for many urologists.

The New York Times reported on March 19 on two large studies – ‘the first based on rigorous randomized trials’ – published on the PSA test.

In summarising the results, the NYT report indicates a Dr Peter B Bach,. a physician and epidemiologist at Memorial Sloan-Kettering Cancer Center as saying ‘one way to think of the data is to suppose he has a PSA test today. It leads to a biopsy that reveals he has prostate cancer and he is treated for it. There is a one in 50 chance that in 2019 or later he will be spared death from a cancer that would otherwise have killed him. And there is a 49 in 50 chance that he will have been treated unnecessarily for a cancer that was never a threat to his life’.

Hmm  … now I know these odds, in future I will not have any PSA tests done.  And that is even before I factor in the incontinence and impotence which treatment might bring.

But reverting to my more professional role as a health economist, why have all these tests been being carried out and at great financial cost to the taxpayer and the private insurance holder? And what about all the anxiety cost they have caused?

I have never been a big fan of fee for service medicine. Doctors are human and if we pay them according to piecework, of course they will do more pieces. Who wouldn’t?

But it is a bit much when they do things which are not evidence based, which can make patients anxious and for which patients struggle to get relevant information on which to make informed choices.

Part of the answer is to look very closely at the heavy reliance our health care system has on FFS medicine. If doctors were paid by capitation (ie by the number of people they serve) or by salaries would there be so many PSA tests?

Will we see the end of the epidemic of PSA testing? Will we see a decline in the dominance of FFS medicine?  And will clinical trials and especially trials of screening tests please take more account of unnecessary anxiety for patients!

Comments 1

  1. Jon Hunt says:

    Sorry Professor, but I think that you have spent too much time studying economics and not enough time studying medicine! It is not a very well-reasoned article.

    What is it that you trying to imply? That doctors do the test hoping that it will be positive so they can make a few dollars? A bit unethical of them isn’t it? This article suggests more questions than whichever one it answers.

    For instance, how do you know the patients were not given the same information as you quoted but asked for the test regardless, because they can live with impotence and incontinence but not cancer? You seem to suggest that the study you mentioned is new, how do you know that previous research hadn’t suggested you should do a PSA?

    For your information, routine PSA screening hasn’t been recommended for several years at least. The sensible question to ask is, why weren’t these guidelines being followed, which seems to be your assertion, although you don’t give any evidence this may have been the case.

    The problem with not using FFS is that it doesn’t matter how much work you do you get paid the same, so perhaps I should call in for a Monday sickie once in a while like everybody else.

    You suggest that: “Doctors are human and if we pay them according to piecework, of course they will do more pieces. Who wouldn’t?” Yes. And there is something wrong with doing more work? Or, rather, getting paid more to do more work?

    Your basic assumption is that too many PSA tests have been done with the aim to improve the income of, I guess, urologists. Unfortunately you have not presented any evidence that I can see that this is the case.

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