What Obstacles?

From my last post, a couple days ago:

The obstacles to treating asthma this way are numerous, complex, and mutually reinforcing, like the obstacles to anything new. Fascinating villains, at least to me. And if I tell this story right, also troubling to any reader who might stand to benefit from this idea that she’ll never get a chance at.

So, what obstacles?

Obstacle 1. We don’t even know if this works for more than a few people.
There are a few heartwarming anecdotes, but no denominator. To find out how many people might benefit, someone’s going to have to spend money to collect careful data.

Obstacle 2. There’s no way to figure out who might benefit from better air.
When heating oil became expensive following the 1974 oil embargo, building contractors created a product called the home energy audit.
It tells you, with perhaps exaggerated precision, how much money you’d save if you made certain home improvements. So the insulation, the air leak caulking, and UV-blocking windows get installed. And the energy-efficiency industry was born.

Would-be healthy-home contractors don’t have such a paradigm. They can test indoor air for substances that are unhealthy at high concentrations. They cannot test the occupants for sensitivity to those airborne substances. For now, indoor air improvement is a gamble.

Obstacle 3. Who breathes better? Who pays? And who saves money?
Linking those who benefit, in health and in reduced medical expense, with those who pay for healthy home improvement is surprisingly difficult.

One scenario: The homeowner bears most medical expenses, pays for work on their home, and saves the money. Simple.

Another scenario: The family’s insurance company bears most medical expenses. A retrofit may cut medical expenses, but in a fragmented insurance market, this family will probably have a different insurer in the near future. If the family’s current health insurer pays for a home retrofit, the insurer’s competitor may reap the benefit in reduced health cost for this family. For this reason, most health insurance companies are reluctant to cover preventive services. The structure of any industry determines its incentives and disincentives.

Yet another scenario: Health costs are borne by a state Medicaid program. A state housing authority could provide a retrofit. Medical expenses might decline by more than the cost of improving the housing. But would the housing authority benefit from the savings in another agency’s budget?

Obstacle 4. Doctors don’t think like that.
Doctors could be gatekeepers, seeing and identifying people with asthma who might do better breathing better air. But doctors are trained to respond to illness with medications.
I’m a doctor, trust me, we use what we know. We feel responsible when we prescribe medications, because we have detailed, formal evidence that they work. (Some of that evidence is questionable, generated to profit drug companies, but still.)

We don’t feel ethical recommending treatments that don’t meet that standard of evidence, like home ventilation. A lung specialist told me that patients ask him what air cleaner to buy. He agrees that air cleaners help, but he has no idea what to recommend.He knows exactly what drugs to give, because his colleagues discuss medications constantly, and drug companies provide them with easily digested forms of evidence over lunch.

I’m afraid the pharmaceutical model is built into most doctors.