The Cost of Human Nature

Is a test that costs $800,000 to add one year of life worthwhile? In one survey, most physicians said yes-evidence that controlling costs will require overcoming very powerful, and irrational, psychological forces.
Imagine for a moment that you are in charge of the U.S. health care system, and must decide whether to pay for a new cervical cancer screening test, let’s call it PapFinder. For every $800,000 spent on PapFinder, health care providers will add one year of life to the population of women receiving this test. Given this information, would you choose to add PapFinder to the standard diagnostic arsenal?
About a decade ago, I presented a national sample of U.S. physicians with a question like this, and almost of them stated that PapFinder (a hypothetical test, by the way) was too expensive, bringing benefits so rarely that they would not offer this test to their own patients. The desire to prevent and treat cancer, it seems, had limits.
Or did it? I presented a random sample of these physicians with a different choice. I asked them whether they would offer annual pap smears (well-established tests in routine clinical use) if they learned that the tests cost more than $800,000 to save one year of life – a figure that came directly from the medical literature. Given this information, physicians were nearly unanimous in saying they would offer their patients this test.
Same cost, same infrequent benefit, but very different attitudes. What’s going on here? And what do the results of this decade-old study tell us about the recent hubbub around mammography screening and, indeed, about the ongoing health care reform debates?
For starters, health care economists are nearly unanimous in holding that interventions that cost more than $800,000 per life year are not a wise use of resources. (Most endorse cost-effectiveness thresholds closer to $100,000.) That means that doctors’ attitudes toward PapFinder appeared quite rational: lots of money, little benefit … not a smart idea.
Why, then, did doctors remain enthusiastic about pap smears even after learning about the $800,000 figure? As a physician working in behavioral economics, I am quite familiar with the irrational forces influencing people’s attitudes towards health care interventions. In this case, a lot of such forces were at work. 
For starters, physicians were influenced by loss aversion. People don’t like having things taken away from them. Doctors were used to providing annual pap smears to their patients, and they knew that their patients would be upset if they no longer offered such tests. We see parallels in current mammography debates, with many women in their 40s responding anxiously to the idea of no longer receiving annual mammograms.
Second was the belief that earlier detection of cancers is always better than later detection, a belief that has also influenced the mammography controversy. This idea is not supported in the medical literature.
In fact, medical science has discovered that some early cancers pose little threat to people’s lives, with the cancers growing so slowly that any intervention to thwart them would cause more harm than benefit. We’ve even learned that some cancers can regress over time. But these cold hard medical facts stand little chance against the hot passions of cancer psychology: doctors and lay people, understandably frightened by the thought of cancer, cannot believe that early detection could be anything but good.
Third was the limited human attention span. When we contemplate important decisions, it is difficult to consider all of the relevant factors, and thus we focus our attention on the most obvious ones. Deciding whether to live in Michigan or California, for instance, we think about the weather while ignoring other important differences between these two states – differences in daily commuting, for example, a factor that has been shown to have far more impact on people’s lives than climate. 
Similarly, when people make decisions about cancer screening, they focus most of their attention on cancer – if the test detects cancer, they conclude it must therefore be worthwhile. People don’t pay as much attention to other aspects of the test. If it mistakenly characterizes a benign lesion as cancer, for example, it will cause undue anxiety or even lead to unnecessarily and potentially harmful treatments. But we don’t give such factors much weight when contemplating whether to utilize the tests.
Everyone who cares about this country should care about finding ways to reduce health care costs. The recent debates over mammograms reveal just how difficult it will be to achieve this goal, for controlling costs will require us to overcome very powerful psychological forces. The biggest impediment to successful reform of our health care system, thus, is not blue dog democrats or obstinate republicans. It is human nature.
To read the original post in the Hastings Center’s Health Care Cost Monitor, click HERE.