Monday, July 27, 2009

Rationing. There. I Said It.



Thirty percent of Medicare money, it's said, is spent in the last month (or is it six months?) of recipients' life. It shouldn't be surprising: people who die are generally sick. Sick people -- especially ones that die -- require more care than healthy people, or people who survive an illness. But it gets to the most thorny of issues when tackling health care costs. And it's a perfect example of why real reform is next to impossible: our politicians are too venal and stupid, special interests are too powerful, media are too superficial, the issue it too freighted with grayness, and the public is too easily distracted for there to be a meaningful discussion.

Notwithstanding the truths just enunciated, I have a few things to say. A proposal, too.

Absent having all the money in the world to spend on health care, I think it's fair to say that everyone is in favor of rationing. If all we had was a million bucks, would anyone choose to spend it on ten demented ninety year olds with advanced cancer and a 5% chance of recovery, instead of ten ten year olds with leukemia, with an 80% chance of recovery? So, like the old joke, we're not really arguing about rationing; we're haggling over details. Not to mention the fact that rationing, so loudly decried by the Foxoid among us as possible under "Obamacare" (whatever that is) is already happening with private insurance: of the dozens of plans offered by each of the twelve hundred insurers, how many cover all things for all people with all conditions under all circumstances? How many people get dropped after an illness, or refused in the first place? Wouldn't it be better to have such decisions made in a system open to public and medical input? (Along those lines, here's a pretty good, and humorous, commentary on the reality we currently face, still defended most arduously by the nay-sayers of the right-wing persuasion.)

End of life care presents us with some of the most difficult decisions we make, as families, as patients, as physicians. Likewise the related situation of "futile care." In neither case are there clear criteria to guide us. The exact same operation -- say, bowel resection for perforation -- would certainly be futile in that ninety year old (let's add some heart and kidney disease to make it easier), and entirely reasonable in a thirty year old, even if that person presented in septic shock. In the latter case I wouldn't hesitate for a second. In the former, I would try (and have, many times) to present for consideration the option of providing comfort care only. I won't psychoanalyze myself, but I hated doing operations wherein I felt there was virtually no hope of survival. (Need I mention that I made more money when I did operate than when I didn't? Yet I tried like hell not to, by presenting as candidly and openly as possible what I thought the situation was.) Not every surgeon would have done so.

I was always scrupulous about cost in my practice, from the little things to the big ones. Saving a few bucks on every case by not demanding different suture for every step when it made no difference: it adds up. So does thinking twice before heading down the road to futility. But it's neither universal, nor easy to know the signposts. Ought there to be some guidelines at the end of life, or should it be up to serendipity? I don't want to take judgment out of the equation; but not everyone has the same capacity for it. Which is part of the problem.

I can't back this up with any data, but when their grandma was dying, it seemed to be those who'd been with her the most who were the most able to let go. It was the out-of-town shirt-tail relative who blew in at the last minute who seemed to demand that "everything" be done. In those circumstances when it was insisted I go for the one/million shot, I've wondered if the same decision would be made were the family responsible for the cost.

So here's my proposal, in the context of the brouhaha over the idea of studying what works, and not paying for what doesn't: let's lay the money on the table. If a family wants to go ahead with an operation or other intervention, for which the odds of success are very long, or which is judged ineffective based on research (let's not get into details for now), here's the deal: if it works, Medicare (or is it Obamacare?) pays. If it fails, the family pays. Cash (credit card?) up front. Takers?

I see this health care "debate" as the quintessential test of our democracy. The need for reform is clear; the trajectory is, without doubt, toward disaster if changes aren't made. And yet, here we are, bogged down in disingenuous rhetoric, in overt efforts to stop it for purely political reasons. Trading amendments and concessions to various profiteers like bubble gum cards. Watering down the most serious proposals like potted plants. Media covering it lazily (all of them), sensationally (most of them), or entirely falsely and politically (you know who.) Advertisements and talking points designed to frighten, inflame, misinform. Citizens unwilling to think about it carefully. Faced with a crying need and a failed future that is not seriously in doubt, we seem unable to have serious debate, to argue on the merits, to legislate the sorts of changes that are needed. How can other countries have done it, and not us? And what does it say about our political system?

Can a nation of half-educated people, unable or unwilling critically to evaluate data; a media industry degenerated into selling soap over meaningful reporting -- and, worse, owned, operated, and scripted by people with overt political agendas; legislators elected for their dogmatism above all, the less serious the better; political parties more interested in power games than doing right -- can such a political system meet real and serious and undeniably needed challenges, or not? We'll know pretty soon. In fact, I'd say we already do.

10 comments:

mibsphil said...

Bravo. As always, well said and exactly on target.

Adjuster Mike said...

Americans have short attention spans. Thus, the number of readers of your post is conversely affected by the length of said post.

AlisonH said...

What a brilliant idea!

Anonymous said...

I personally think that everybody understands the need for rationing, and in some ways is willing to accept it.

Just not for their mother. Or grandmother. Or father. Or auntie. Or son.

For your demented 90 year old grannie with free air though, well, operating just doesn't seem to make sense.

Anonymous said...

This is the kind of brillance we're looking for in this debate. If it works, we pay. If it doesn't, you pay. Great.

How do we secure payment? If payment isn't made do we take cars? Houses? Wages? Food?

Never mind the details, it's a great idea.

At least we won't have tort reform where the loser pays attorney fees. That wouldn't make nearly as much sense as taking someone's house because their spouse died.

Isn't it fantastic we have the intellectual half of the masses to keep those idiots who actually express a different view in line. Continue to show them how debate is great as long as it always ends in agreement with the liberal point of view.

Saving on sutures is great. When you're willing to cut costs by 40%, including your income, then you can credibly comment on rationing.

Sid Schwab said...

Guess you didn't read the conditions under which the "idea" would be in play. Not only was it not really serious, in that it'd never happen, it was only under the circumstances when someone insisted on care that's been shown to be ineffective. Billions are spent on the last month of life, much of which is on futile care. Not many have the guts to bring it up and propose solutions, of any kind.

Actually, payment for surgical procedures is about 30% of what it was 30 years ago. The biggest costs are not in physician fees, but in the costs of hospital care.

Funny, that. Obama has suggested ways to reduce those costs. Response? Demagoguery and disinformation by the previously cost-conscious Republicans.

Glad to know the threshold for a physician being able to comment on rationing: 40%. Thanks for that.

Anonymous said...

I totally agree with the idea of cutting costs. I also think it's complete bull that Obama believes it. Where has the cost efficiency of Medicare been thus far? It's broke by any reasonable standard. Did I see somewhere were someone said it's not broke, it's just not funded enough? That's the most hilarious thing. It's truly a no lose proposition: If it's spending more money we just haven't spent enough to show how good it is. And think what we would've spent without it!

Expand the Medicare pricing to every payer. Implement the fantasy cost saving plan of Obama on Medicare, let it work for five years, and if it has demonstrably cut costs compared to other payers. If it has, let's expand the program. If it hasn't, take what you can from it but throw single payer as the end all solution on the trash heap.

Sid Schwab said...

Like many, you dismiss what Obama says. Fine. Time will tell.

I'll speak more slowly: the problem with Medicare solvency is not about something wrong with Medicare. It's about the rising costs of care , versus the way in which it's funded. Insurers have tripled premiums in the past few years . Medicare funding has not . If medicare were funded like private insurers we'd see lower costs compared to private insurance because it doesn't suck money out in high salaries and profits. No matter the payer , costs of care itself must be cut. Switching to single payer , in comparison to having multiple insurers would save money. But the real savings are to be had in addressing the ways in which care is delivered. You want to cut costs by 40% . Me , too. If you have a way without reducing the amount of care (ie rationing) or looking at the savings Obama implies , let's hear it.

Anonymous said...

I'll try to take the positives from your comment but I want to expand on one of them.

You claim that insurance has gone up but Medicare hasn't. Providers add any losses they have on Medicare to privately insured patients, which is now about $1,800 per year per insured family. Without that cost shifting and with Medicare bearing its own true costs, it would be beyond broke. It's still going broke in 2017 even with those advantages. Enough on that.

There should be a serious discussion on the future of healthcare and its associated costs, but there hasn't been. Both sides, including you, are tied to their own special interests. I've read your blog and you end up just ignoring anything that doesn't comform with set views. Your opposition has the interests of big business instead of big government and physicians in mind.

Neither side is sustainable and in my opinion the truth is somewhere in between. Healthcare has certain aspects of a socialist underpining but we live in a capitalist society. Too many see those as incompatible - much as it appears you do.

As a society (the socialist part) we should take care of those who can't take care of themselves. To cut it short, a Medicaid plan. What we currently have is a system where we have a lot of 'uninsured' who suddenly are insured under Medicaid as soon as they need care. Why not expand that idea to those who are unemployed, poor, etc. but use the same insurance company and receive support through government programs.

On the other hand, encouraging self reliance strengthens society. I also believe government falls prey to special interests and that's a death knell for single payor. Medicare has never reduced costs without shifting the costs or subsidies from other government funding - and it's going broke despite that. Expanding that program with the idea its going to magically change remains a fantasy.

To encourage self reliance, we don't need a single payor or socialized system. We do need a system the encourages free competition but protects the rights of those who are and have been responsbile. That means three primary changes to the system are mandatory: mandated insurance (semi-socialist), subsidize those that can't afford it (semi-socialist), and when you have it you need to have fair protections (capitalist/gov't).

Outside of that, we should look at how we can encourage our capitalist underpinnings. That encourages competition and innovation - amongst providers, researchers, drug companies, and, yes, insurers. To do otherwise is to protect the interests of certain groups against those of others.

The rest of the worlds systems are relying more, not less, on private insurance. It's not insurance that's evil, it's having a system that doesn't mandate coverage and results in incredible amounts of time spent protecting those that have responsibly bought insurance from those who wanted to suck off the system and buy coverage only when they need it. Or, it didn't protect those who bought responsibly and got in a spot where they couldn't afford it.

Those are the broad outlines of a system that's far more in line with our general society and current structures. The next part is your question regarding cost cutting, which comes to this: Is the government set up to ration healthcare? It hasn't with Medicare one bit. As society ages, technology gets more expensive, and new high cost drugs are developed, what evidence is there that the government as a single payor would control costs? None. Countries like Switzerland, Germany and Japan use insurers and they're doing it at lower cost than us. Why?

Think for a minute about the previous post. Experiment for five years with three plans. Try yours, try mine, try Obama's. See which works. Expand it.

Instead, you seem to want to count on Obama's plan that costs over a trillion (not counting tax and fee increases), not address underlying costs (your salaries compared to other countries), and blame insurers. Too bad.

Sid Schwab said...

Oh man, I just spent twenty minutes on a lengthy response to the previous comment and somehow it didn't post. The prospect of doing it again is too much. Too bad. It was really good. Not that it would have changed any minds.

I'll say these things briefly, though:

I don't like the current plans in Congress.

My "salary" was, it seems, about a quarter of what you claim for your friends. I don't disagree that some docs make too much, and provide too little for it. I didn't. I worked 80 hour weeks, made rounds 2, 3, 4 times a day, saw my patients every day, every weekend, on or off. As reimbursement went down and down every year, I worked harder and harder to stay even, and eventually burned out, ten years too soon. If you get surgery nowadays, don't expect that kind of attention. You won't get it.

Payers -- whether medicare or insurers -- can only do so much to control costs. It requires attention, as Obama has said, to how we deliver care; why people like me were able to produce better results at lower costs than others; why in my home in the Pacific NW costs are significantly lower than, say, in the NE.

I'd love to see regional experimentation. Bush quashed the Oregon plan; there's one in SF that's very intriguing, with no interference from Obama.

You'll never see my point, evidently, about medicare's financial problems. So I won't bother to repeat myself.