BY NORTIN HADLER, MD (3)
In an editorial in the Journal of the American Medical Association last October, two of Harvard’s more influential economists, David Cutler and Lawrence Summers, called COVID-19 the “$16 Trillion Virus”. This is their estimate of health expenditures and lost income through the summer of 2021 barring important mitigating medical and/or policy interventions. That astronomical sum represents 90% of the annual gross domestic product, which translates into a loss of $200,000 for a family of 4. Approximately half represents diminished income consequent to job loss and the COVID-19 induced recession. The other half is in expenditures related to premature death and long-term physical and mental health impairments.
Cutler and Summers do not focus on the costliness of treating acute SARS-CoV-2 infections. These are economists who are keen on following the money. It turns out that during the early months of the COVID-19 pandemic when Intensive Care Units in many cities were overrun with patients requiring costly and labor-intensive care, health care expenditures in the country plummeted, as much as 50%! The decrease in healthcare expenditures reflects decreases in outpatient and inpatient utilization across the age spectrum and was particularly dramatic for those with private health insurance. Obviously, many found the need to seek medical care more discretionary than they had prior to the pandemic. Some of this behavior represents avoidance resulting from concerns that healthcare facilities were sources of infectivity. Much of it represents reframing the notion of “elective” procedures.
Elective is a clinical term that denotes options in the timing of the intervention, not in the indication for the procedure. “Elective” is an intervention that can be postponed rather than an assertion that it can be avoided. “Elective” is a judgement of the prescribing clinical practitioner; discretionary is the judgement of the patient as to how necessary it is. The decrease in volume was striking for clinical specialties like orthopedics that offer costly “elective” interventions. This decrease more than compensated for the cost of caring for patients with SARS-CoV-2 infections. It also wreaked havoc with the bottom lines of hospitals, clinics, and private practices but not the purveyors of pharmaceuticals. Congress has not shied away from bailing out shaky clinical institutions.
This dialectic forces a reconsideration of the concept of “elective” interventions. FDA licensure is a degree of certainty that the benefit exceeded the risk from a particular pharmaceutical in randomized controlled trials but does not speak to by how much for any given patient. For devices the FDA’s licensure only speaks to likelihood of adverse effects, not the likelihood of benefit. Who decides when a benefit is sufficiently likely and meaningful to comport with the values of the particular patient? The patient has a conflict of interest in this regard. The prescriber should not. Hence, all “elective” interventions are discretionary. This is a question of propriety, which is central to notions of health and caring. The answer is the driver for the size, scope and power of the American institution of health care. The pandemic has made this transparent and moves patient empowerment to the forefront of healthcare policy and ethics.
Nortin M. Hadler, MD is a graduate of Yale College and Harvard Medical School. He joined the faculty of the University of North Carolina in 1973 and has been a professor of medicine and microbioogy/immunology since 1985. His assaults on medicalization and overtreatment appear in many editorials and commentaries and 5 recent monographs: The Last Well Person (MQUP 2004) and UNC Press’ Worried Sick (2008), Stabbed in the Back(2009), Rethinking Aging (2011) and Citizen Patient (2013).