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Scoping Out the Screening Market
Editorials and Commentary
Scoping Out the Screening Market Bard C. Cosman, MD, MPH, FACS, FASCRS
W
ork follows money in a capitalist economy, and work follows resources the world over. Not surprisingly, economic realities govern the supply and demand for endoscopic screening for colorectal cancer as well, and economic factors dictate why screening in the United States is deficient. Endoscopic colorectal cancer screening is one of the most effective preventive health interventions known, and were screening applied universally, colorectal cancer could be nearly eradicated, an achievement similar to the effect of Papanicolaou smears on cervical cancer. As a colon and rectal surgeon, I see every case of colorectal cancer as a failure of screening, and I view each death as one that could have been prevented. The Tangka article1 in this issue suggests some economic reasons why public and provider education— factors that primarily increase demand— have not been able to increase the volume of endoscopic screening sufficiently in the population, and it sets forth a framework for health policymakers to consider supply as well as demand. Unlike many medical decisions made under duress of pain or illness, the decisions surrounding screening—whether, how, where, and by whom it should be done—are usually made by consumers with ample time and (thanks to education campaigns) adequate information. Providers likewise can count on steady demand for as much endoscopic screening as they can provide, so they can decide a priori how much screening they are willing to do. When both parties have adequate time and information for their internal deliberations, one can expect an economic model to operate, in which the consumer maximizes satisfaction and the provider maximizes profit. If screening endoscopy— unlike much of what we physicians do—takes place in a rational world of economic laws, one may look to those laws to see why population screening is not happening. For example, Table 1 in Tangka et al.1 shows how a primary care provider has an incentive to do no more than 30 office sigmoidoscopies per month. While health services planners might envision turning medical practices into endoscopy factories efficiently churning out countless procedures, current economic realities ensure that this cannot happen. The graphical model in Appendix 2
(Tangka et al.,1 provided online at www.ajpm-online. net) illustrates the critical role of marginal cost in determining how many procedures any provider performs. Spurred by a recent Nobel Prize for psychological economics, there has been much recent talk about the unreality of homo economicus, the hypothetical rational person who maximizes well-being, and about the need for more consideration of irrational, psychological elements in economics. However, few providers do screening endoscopy for the intellectual challenge, variety of experience, or professional prestige that it confers. Also mostly absent is the humane satisfaction of curing a patient’s illness or devising an effective treatment plan. The gastroenterologist who takes on a difficult Crohn’s disease patient and the colorectal surgeon who accepts a complex cancer case both view screening endoscopy as a background activity, something that will always be there to finance the less profitable, more interesting areas of their practices. If it fails to finance other areas, then it will not be done—and we are back to the rational laws of classical economics, to viewing providers as homines economici. Tangka et al.1 is a thought-provoking article that provides no answers, but it does review in a systematic way the factors that affect demand for endoscopic screening, and the more important factors that affect supply. One can imagine using the organized approach taken here to design a regional model colorectal cancer screening program that could function better under current economic conditions. In a more visionary mode, one can imagine making regulatory changes to increase the healthcare system’s endoscopic screening output. Aside from the obviously necessary reimbursement hikes, this might involve deregulating some aspects of the endoscopic screening process, to make it more responsive to the market demands that are actually out there. This economic description of the market for endoscopic colorectal cancer screening is a refreshing complement to the blue ribbons, blue stars, and Colossal Colons of the education campaign that we all endorse so enthusiastically.
Reference From the Halasz General Surgery Section, VA San Diego Healthcare System, and School and Medicine, Surgery, University of California, San Diego, San Diego, California
76
1. Tangka FK, Molinari N-AM, Chattopadhyay SK, Seeff LC. Market for colorectal cancer screening by endoscopy in the United States. Am J Prev Med 2005;29:54 – 60.
Am J Prev Med 2005;29(1) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.04.001
Scoping Out the Screening Market Bard C. Cosman, MD, MPH, FACS, FASCRS
W
ork follows money in a capitalist economy, and work follows resources the world over. Not surprisingly, economic realities govern the supply and demand for endoscopic screening for colorectal cancer as well, and economic factors dictate why screening in the United States is deficient. Endoscopic colorectal cancer screening is one of the most effective preventive health interventions known, and were screening applied universally, colorectal cancer could be nearly eradicated, an achievement similar to the effect of Papanicolaou smears on cervical cancer. As a colon and rectal surgeon, I see every case of colorectal cancer as a failure of screening, and I view each death as one that could have been prevented. The Tangka article1 in this issue suggests some economic reasons why public and provider education— factors that primarily increase demand— have not been able to increase the volume of endoscopic screening sufficiently in the population, and it sets forth a framework for health policymakers to consider supply as well as demand. Unlike many medical decisions made under duress of pain or illness, the decisions surrounding screening—whether, how, where, and by whom it should be done—are usually made by consumers with ample time and (thanks to education campaigns) adequate information. Providers likewise can count on steady demand for as much endoscopic screening as they can provide, so they can decide a priori how much screening they are willing to do. When both parties have adequate time and information for their internal deliberations, one can expect an economic model to operate, in which the consumer maximizes satisfaction and the provider maximizes profit. If screening endoscopy— unlike much of what we physicians do—takes place in a rational world of economic laws, one may look to those laws to see why population screening is not happening. For example, Table 1 in Tangka et al.1 shows how a primary care provider has an incentive to do no more than 30 office sigmoidoscopies per month. While health services planners might envision turning medical practices into endoscopy factories efficiently churning out countless procedures, current economic realities ensure that this cannot happen. The graphical model in Appendix 2
(Tangka et al.,1 provided online at www.ajpm-online. net) illustrates the critical role of marginal cost in determining how many procedures any provider performs. Spurred by a recent Nobel Prize for psychological economics, there has been much recent talk about the unreality of homo economicus, the hypothetical rational person who maximizes well-being, and about the need for more consideration of irrational, psychological elements in economics. However, few providers do screening endoscopy for the intellectual challenge, variety of experience, or professional prestige that it confers. Also mostly absent is the humane satisfaction of curing a patient’s illness or devising an effective treatment plan. The gastroenterologist who takes on a difficult Crohn’s disease patient and the colorectal surgeon who accepts a complex cancer case both view screening endoscopy as a background activity, something that will always be there to finance the less profitable, more interesting areas of their practices. If it fails to finance other areas, then it will not be done—and we are back to the rational laws of classical economics, to viewing providers as homines economici. Tangka et al.1 is a thought-provoking article that provides no answers, but it does review in a systematic way the factors that affect demand for endoscopic screening, and the more important factors that affect supply. One can imagine using the organized approach taken here to design a regional model colorectal cancer screening program that could function better under current economic conditions. In a more visionary mode, one can imagine making regulatory changes to increase the healthcare system’s endoscopic screening output. Aside from the obviously necessary reimbursement hikes, this might involve deregulating some aspects of the endoscopic screening process, to make it more responsive to the market demands that are actually out there. This economic description of the market for endoscopic colorectal cancer screening is a refreshing complement to the blue ribbons, blue stars, and Colossal Colons of the education campaign that we all endorse so enthusiastically.
Reference From the Halasz General Surgery Section, VA San Diego Healthcare System, and School and Medicine, Surgery, University of California, San Diego, San Diego, California
76
1. Tangka FK, Molinari N-AM, Chattopadhyay SK, Seeff LC. Market for colorectal cancer screening by endoscopy in the United States. Am J Prev Med 2005;29:54 – 60.
Am J Prev Med 2005;29(1) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.04.001