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Learning from the Mammography Debate

mgullettes Icon Posted by Margaret Morganroth Gullette

December 1st, 2009

The spontaneous eruption over the new mammography regulations, and the confused history of the debate, warn us about the general relationships between government-issued medical guidelines, insurance coverage limits, and doctors’ discretion.

The final health care bill that comes out of Congress should have language declaring that guidelines–even the latest and best guidelines–do not mandate reduction of coverage or permit public or private payers to deny reimbursement to doctors who order the procedure and patients who want it.

In this specific case, the law might say that payers cannot deny reimbursement for mammograms for women over forty–or for women at high risk at any age. African-American women, I learn, are more likely than White women to get breast cancer under age forty. There is probably no guideline for which there are not exceptions, as good clinicians like to observe. Age-related guidelines require even more caution. Guidelines are useful, especially for doctors who read little. But they are just guides, not rules.

What we want to ensure is that medical research empowers doctors and patients and helps them fight insurance company decisions to deny treatment or ration care by gender or age or race, or by class, disability, or potential cost of treatment.

“By potential cost of treatment” is a particularly important caveat in an era like our own when collective solidarity seems so threatened, when the right-wing is opposed to universal coverage, when we do not know how Medicare will be cut, and when ageism comes garbed in language about saving money for the public.

How could denial of care come about legally, whether for people over 65 or any other targed group?

Step One. It would start with a scientific group that is trusted by the government and entrusted with a task to focus on “evidence-based” or statistical medicine. (In this case of mammograms, the U.S. Preventive Services Task Force –called “ the gold standard for preventive services,” by the Department of Heath and Human Services –produced the new recommendations. )

Women’s health advocates whom I trust support them, although Bernadine Healy does not. The former say that it is just an accident of bad timing that the guidelines–which if followed will save money–come out at a time when the media have made cost-cutting seem nearly a matter of national security. I am braced to learn more about the risks of screening. I, along with many women, have been taught to trust screening and “preventive” care, by our doctors and by public-health campaigns. )

But not all guidelines come highly recommended. The Congressional Budget Office during the Bush-era produced a study in 2005 called, without subterfuge, “High-Cost Care Beneficiaries,” that explored strategies for identifying which kind of Medicare enrollees are likely to be “future” high-cost beneficiaries. These strategies, gerontologist Robert Binstock warned in an essay titled “Our Aging Societies: Ethical, Moral, and Policy Challenges,” could be “a preliminary step for identifying those whose care might be rationed.”

On such a basis, some other panel with medical credentials–it could arise from the National Institute of Health or a leading cancer group–would decide what categories of procedures were likely to be high-cost.

Step Two. What makes a task-force recommendation into policy is legislation that transforms recommendations into statutes governing reimbursement (For mammograms, as CNN discovered, it was single paragraph Paragraph 2712 of the Senate health-care bill, saying what categories could be covered and which could not.)

For end-of-life care, it would involve a Congressional instruction to the Centers for Medicare and Medicaid that refused reimbursement. It might appear in a paragraph that AARP and our other guardians didn’t notice because there was no furor around it.

Gloria Steinem said on CNN, “What we have to fight for is individualized treatment, of course. . . . [T]he important thing is that what is covered is what is recommended by a physician and desired by the patient.” This is true for coverage of women, people under 65, people over 65.

In a cost-cutting era, we can almost prophesy conflicts between evidence-based medicine (which can be promoted in part not only because it’s better medicine but also because it is alleged to save money) and, on the other hand, individualized care.

Dr. Jerome Groopman in the NY Review of Books (December 17, 2009) notes more generally, “A recent analysis of more than a hundred evidence-based conclusions about clinical practice reported that after two years more than a quarter of the conclusions were contradicted by new data, and that nearly half of the ‘best practices’ were overturned at five years.” Groopman is one of the best doctors who write as public intellectuals these days.

Groopman’s primary example is estrogen–hormone “replacement therapy” as it was so long called. Doctors had doubts about it even as it was being urged on women in their forties for the rest of their lives. Before the hormone debacle, gynecologists were worrying about noncompliance rather than doing extra reading about risk and effectiveness.

What Medicare-for-All (aka national health) ought to deliver is quality treatment person by person, not rules that limit the health care we get because of any group attribute.

Margaret Morganroth Gullette is a Resident Scholar at the Women’s Studies Research Center, Brandeis, and the author of Aged by Culture.

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