Book Review

Medicine Worth Paying For: Assessing medical innovations

N Engl J Med 1996; 334:1482May 30, 1996

Article

Medicine Worth Paying For: Assessing medical innovations
Edited by Howard S. Frazier and Frederick Mosteller. 311 pp. Cambridge, Mass., Harvard University Press, 1995. $39.95. ISBN: 0-674-56362-X

If we Americans were as committed to the bottom line as we are reputed to be, we would long since have arranged for every child's vaccinations. Nothing offers a better return on the dollar than measles inoculations, as editors Howard S. Frazier and Frederick Mosteller note in Medicine Worth Paying For. “Few medical technologies actually show a profit — save more money than they cost — but vaccines for preventing measles do. . . . Over a twenty-year period starting in 1963 . . . a savings of $5 billion from reductions in later health care and increased productivity was realized.”

The 14 case studies in this provocative book reveal that the bottom line is not our measure of value, nor is the simple saving of lives. In fact, there is no uniform measure. Frazier and Mosteller, who are retired from the Harvard School of Public Health, reflect the influence of Howard Hiatt, who as dean of the school starting in 1972, introduced a multidisciplinary approach to understanding health care. In that spirit, this book presents a powerful argument for applying statistics and epidemiologic data to the assessment of medical innovations.

Among other things, Frazier and Mosteller recommend more and simpler clinical trials, randomized clinical trials with a double-blind component, and long-term follow-up. They use the history of diethylstilbestrol as a worst-case example, recalling how this medication was introduced in 1950 to prevent miscarriages, without any systematic testing. The effectiveness of diethylstilbestrol was examined in 1956, and evaluations showed that it had led to an increased number of premature births, but these results were ignored, and the drug continued to be prescribed for 25 years. The results, as we know, were cancers in the offspring of the women who took the drug, as well as serious reproductive problems that are now appearing in the grandchildren of the original patients.

Unanticipated effects of treatment are implicit in any medical intervention, which suggests that all treatments should be monitored at every stage. A chapter on peptic ulcer discusses the introduction of endoscopy for diagnosing peptic ulcers as an example of a rush to embrace novelty without safeguards. The author notes the increased mortality associated with the diagnostic procedure, even as it was adopted widely without ever having been subjected to comparative randomized trials.

Targeting relatively easy areas of reform, the editors note the “perverse financial incentives” built into Medicare coverage of kidney transplantation. Once the expensive procedure has been performed, the often-impoverished patient is abandoned after a year to find some way to meet the high costs of immunosuppressive drugs or to try to live without them.

With so much concern about health care costs, the editors remind us that “the physician serves as advocate for . . . individual patients, not for classes of patients or for society as a whole.” Unmentioned, but obviously a major obstacle, is the fact that fewer and fewer physicians have the luxury of considering single patients in a vacuum when they are bound to the group norms of managed care. The editors mention the perverse financial incentive of reimbursement for transplantation but not the perverse incentive of rewarding physicians according to what they do not do for patients.

This book was obviously written when some kind of national health care scheme seemed almost in hand and desirable. It does not address the problems of the system dominated by private insurance that seems to have slipped in through the back door. Yet most of the book's cases and arguments demonstrate that there is an overall lack of data to evaluate outcomes. This information is critical to the refinement of any health care system, whether a single-payer national plan or a system of competing managed-care providers.

Bettyann Kevles, M.A.
Art Center College of Design, Pasadena, CA 91105