British health economist James Buchanan D.Phil. is skeptical that Geisinger Health System’s (Pa.) genomics project will prove to be cost-effective. But what about the cost-effectiveness of the whole U.S. health system?
As a physician and resident of the southern reaches of Geisinger Health System’s catchment area in central Pennsylvania, I was intrigued by Dr. Buchanan’s blog on Geisinger’s population-based MyCode genomics project. This project was featured in October 27, 2017, issue of Science.
Dr. Buchanan’s skepticism is undoubtedly warranted about the cost-effectiveness of costly screening of thousands of patients, unselected for any traits or conditions, across generally low-risk populations.
Geisinger’s Intent Is Not Cost-Effectiveness per se
However, I would comment that Geisinger’s intent – reflected in its motto, “Heal, Teach, Discover” – is not in the first instance cost-effective screening. Rather, Geisinger is motivated by scientific discovery and community service. In the process, its MyCode project has had the side benefit of enhancing Geisinger’s academic and clinical reputation to attract clinicians, resident trainees, academics and ultimately patients to this otherwise rural, non-cosmopolitan region. Geisinger has sustained its support of this project since 2006 based on its vision and ideals, free from any profit motive or mere search for efficiency.
I would further comment that the profit-motive-driven quest for efficiency will not always converge with genomic research applications. A case in point was contemplated at a recent NEJM Catalyst webinar by Harvard Business School’s Professor of Social Policy Amitabh Chandra’s thought experiment about the “value” (to society) of life-saving curative treatments when their economic price is exorbitant. This scenario will likely emerge from new gene-editing technologies currently under development. Professor Chandra’s solution is to create a public research entity that would bear the cost of development but also own the intellectual property rights. Thereby life-saving gene-based treatments would be provided without regard to shareholder “return on investment.”
Britain’s National Health Runs on Cost-Benefit Analysis
I have also been interested in use of cost-effectiveness analysis to guide public health policy. Cost-effectiveness analysis is being done in the United Kingdom by the National Institute of Clinical Excellence (NICE) to guide budgeting for new technologies. Similar research is being done in the U.S. by the Institute for Clinical and Economic Review (ICER). Its application to pharmacoeconomics has been promoted by a for-profit data analytics company based in Massachusetts, BHE Analytics, and was the subject of a pharmacoeconomics conference in Glasgow in November 2017.
Will Cost-Benefit Approach Work in the U.S.?
My particular interest has been in the Oregon Health Plan, which in 1994 innovated the use of cost-benefit analysis to prioritize services provided by its Medicaid program. I would be interested in Dr. Buchanan’s perspective on how cost-benefit analysis could be applied at a national level to help the U.S. rein in its health spending, which has now grown to 18% of GDP and shows no sign of stopping.
Image Credit: By Chromatin_chromosome.png: Magnus Manskederivative work: NEUROtiker ⇌ – Chromatin_chromosome.png, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=7921881