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Tante ML Graaatiis, Jakarta, Bandung, Surabaya, Jogja, Solo, Semarang, Lampung, Balikpapan, Makassar, Bali, Jambi, Batam, Serang, Palembang, Cirebon, Padang, Medan, Sorong, Aceh dsini tempatnya.

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Radiologists are cheering a recent study unequivocally demonstrating that CT screening for lung cancer saves lives. Many of us have long held that such screening would be useful, but were previously met with curiously strident resistance(jealousy?) from many quarters. Unfortunately, winning the intellectual argument against the epidemiologists and internists is only part of the battle. In today's environment, not only does screening have to save lives, it also has to be cost effective. More importantly, this debate about screening demonstrates a fundamental and vitally important flaw in the way we think about healthcare and insurance.

Screening efficiency requires evaluating the cost of both the diagnostic tests and the treatment of the disease itself. HIV screening is an example of a cheap test that prevents an expensive disease. Unfortunately, as the screening tests get more expensive, and the disease treatment cheaper, screening efficiency goes down. Lung cancer is an example of low screening efficiency. CT scanning is an expensive diagnostic test, and lung cancer is disease relatively inexpensive to treat(because people are either cured with surgery or die quickly). Hence the argument against paying for lung cancer screening invokes the high cost of the scans in relation to the eventual cost of treating the disease.

What is missing from this argument is that for the person who smokes, not only is the screening cost effective, it is priceless. Standard economics break down when we discuss the value of life to the person involved. How can you put a dollar value on your own life? Furthermore, for the individual, and their family, the cost to the rest of society is irrelevant. These basic realities lie at the heart of our inability to confront the expensive over-treatment our system encourages. Fortunately, the solution to this dilemma may actually be simpler to resolve than it may first appear. However, doing so may require changing our notions about what health insurance is.

A comparison with car insurance may be enlightening. Bad drivers pay much higher rates than good drivers, and insurance companies are allowed to judge this risk and charge accordingly. One can choose to speed or drive drunk, but must assume the responsibility and pay for the extra risk these activities entail. In contrast, for reasons both historical and societal, health insurance pricing is not based upon the risk profile of the person being insured. Everyone, no matter how irresponsible their personal behavior, pays the same premium. An alcoholic, overweight smoker pays the same rate, gets the same coverage, and has the same policy limits as everyone else in the company, or on Medicare.

Tying risk to benefits may well be a partial solution. How about including the cost of CT screening in the insurance premiums of smokers? The premium could be paid for through a designated cigarette tax. Maybe indexing health insurance costs to body mass index, smoking history, or alcohol intake would motivate people to actually change behavior.

Tante ML Graaatiis, Tante-tante Jakarta, Tante-tante Bandung, Tante-tante Surabaya, Tante-tante Jogja, Tante-tante Solo, Tante-tante Semarang, Tante-tante Lampung, Tante-tante Balikpapan, Tante-tante Makassar, Tante-tante Bali, Tante-tante Jambi, Tante-tante Batam, Tante-tante Serang, Tante-tante Palembang, Tante-tante Cirebon, Tante-tante Padang, Tante-tante Medan, Tante-tante Sorong, Tante-tante Aceh disini tempatnya.

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Of course, such a suggestion has no possibility of adoption now, it is too politically incorrect. Nevertheless, it is vital we begin to discuss the relationship between accountability and responsibility in healthcare. By shifting the cost of a risky behavior back onto those who chose to participate in it, we can simultaneously fund screening and discourage harmful behavior. I wish I could take credit for this idea, but it is not mine, it is called capitalism.

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