In The World Of Rationing, What Are YOU Worth?

Rationing is defined as “the controlled distribution of scarce resources, goods, or services”. In health care, rationing is not a new concept and has been occurring for years, most often in times of emergency but also when resources are merely limited or demand is greater. For example, an increased need for ventilators in the winter months during flu epidemics; organ transplants are dictated by the availability, or the shortage, of hearts, kidneys, lungs and livers; limited numbers of “iron lungs” in the 1940’s for polio patients.

The topic of health care rationing has frequently been a subject of discussion but has taken center stage recently and is on the mind of most every citizen. Health care was one of the major platform issues for every candidate in the 2008 presidential election. As the election heated up, IT became one of the pivotal issues along with the war in Iraq.

Philosopher Peter Singer, the Ira W. DeCamp Professor of Bioethics at Princeton University, Laureate Professor at the Centre for Applied Philosophy and Public Ethics at the University of Melbourne stated the following in an article printed in the New York Times

“If the Department of Transportation [followed the principle that it was impossible to put a dollar value on human life] it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?”

An interesting question since all of us responsible for the family budget do much the same thing on a daily basis. Many times my own children will say “I want….”. and my answer is “There is a big difference between wants and needs.” and that is true for every aspect of life so why not health care?

The idea of rationing health care came from the National Institute for Health and Clinical Excellence (NICE) making a recommendation to the National Health Service that it should not pay for Sutent, a drug to be used for advanced kidney cancer. At a cost of $54,000 it would potentially extend a terminal advanced kidney cancer patient’s life by six months. NICE calculated the cost of a life per year at $49,000, meaning that Sutent was more expensive than a life was worth to save. A huge uproar in England made NICE reverse their original decision, but mostly because it would be used so infrequently as to be a non-issue. This fracas was then used as political ammunition against Obama and the Democrats that the Affordable Care Act amounted to rationing of health care. Duh!

Of course it will. Whether the insurance coverage you receive is from your employer or the government, it will only cover what they can afford to pay. Even the best “Cadillac” health care plan offered by commercial insurance DOES NOT cover every potential illness, condition, prescription or treatment. Will Wilkinson said it like this;

“Individuals trade reductions in risk of death against other goods in the context of their own limited budgets. (I.e., they ration their resources.) What you are willing to pay to reduce the risk of death depends in large part on how much you’ve got to spend. If individuals with a ton of money spend boatloads on medical care, they are thereby revealing how much they are willing to pay to reduce the risk of death and are thereby pushing up the average willingness to pay for extra life. For the government to step in and limit spending on medical treatments on the basis of the fact that the limit reflects the average willingness to pay for extra life is exactly like government stepping in to limit how much individuals can pay for extra safety features on a car on the basis of what people do tend to pay. This stupidly takes an evolving average as normative while cutting off the possibility of further evolution.

Of course the government, like individuals and families, has a limited budget. So if the government is going to pay for medical care, it has to ration. And that very fact is an argument for limiting the government to only paying for the care of people who are unable to pay for a minimum of care themselves.”

This makes sense from the standpoint that those who exploit our current “free” system of universal health care, are the ones that need government sponsored health care. The rest do not and can afford to pay what they feel is an appropriate amount for the level of coverage they receive. It will result in a two-tiered system of health care, but we and every other country in the world have one already.

Even Islamic Pakistan places a value on life. The recent arrest of a US CIA contractor for killing two Pakistani men resulted in his acquittal after “blood money of more than 2 million was paid to 19 family members of the “victims” (the contractor claimed self-defense and the US tried to state he was covered by diplomatic immunity). That gives us $105,263.63, the value each family member placed on the life of each victim killed, at least in Pakistan.

And consider the following tongue in cheek assessment of “value”; A man asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. “So,” he says, “would you have sex with me for $50?” Indignantly, she exclaims, “What kind of a woman do you think I am?” He replies: “We’ve already established that. Now we’re just haggling about the price. And so, we have established that this “value” is negotiable.

The bottom line of the discussion of “rationing” comes down to what is the value of a human life and who will be the one to determine that value. Of course each of us would consider our own selves more valuable than another. Do we take into consideration the value of education, contributions to society, intellect, accomplishments, current chronic illnesses, taxes paid, number of children, pedigree, occupation or merely accept that the value of a life…mine, yours or the President of the United States, is merely an average of all factors combined. Would you be satisfied with that value in exchange for health care for everyone?

Ching!

Doc B.

My opinion is free.
Advice is worth exactly what you pay for it.

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Here Lies Donald Berwick, MD….

It appears that the appointment of Don Berwick, MD as head of CMS has come to an end before it actually started.  The man  with a vision of transforming Medicare into a lean, mean fighting machine, one with quality of care and cost efficiency as its engine.  You can read his bio here, but in short, he has championed more initiatives to improve the quality of care in the United States and likely saved more lives in just a few years than most of us will save in a lifetime.  He championed the “100,000 lives campaign” through the IHI and modified the IOM‘s vision for health care. His dedication to improving health, quality, care and outcomes for all has been applauded by many. So why would a man, with such passion, drive and vision, not be an acceptable candidate, at least in the eyes of our elected political leaders?

In short, he has become the latest casualty in the political battle between Obama, his Democrats and the GOP.  It didn’t help that Obama waited to appoint Berwick during a congressional recess, even though he has every right to do so.  Americans, at the time of the elections last fall, were being bombarded with anti-Obama everything, high unemployment, rising foreclosures, bankruptcies and the thought of higher taxes for “Obamacare”.  Berwick was and is caught up in the wave of negative sentiment towards Obama and supporters.  The Republicans are taking full advantage of this negativism and trying to make good on their threat to repeal the health care bill….completely, as if there are no parts of it worth saving.  An additional aspect of this is their relentless bashing of Berwick and their refusal to consider his appointment before the confirmation hearing had even begun.  Some Democrats have already jumped aboard the bandwagon and, alongside their GP foes, begun asking for additional potential nominees to be named.

At the center of much of the press against Berwick are the comments he made regarding the National Health Service in the UK.  One aspect of their medical program is the concept of rationing and for the Republicans, a key issue they have spun into sentiments most foul.  Although Berwick has declared that he favors evidence based, clinically relevant and successful medical care, he has not stated he favors rationing, with black and white lines between who will and will not receive needed care.

Many in the medical community have expressed their support for Dr. Berwick and their outrage at his treatment in the press at the hands of the Republican naysayers. Among them are Dr. Robert Wachter, health economist Jonathan Gruber and, without an outright endorsement, the AARP. Of course there will always be those who have nothing good to say about anyone or anything.

I have always told my children that the only opinion that matters is one that comes from a reputable source or from someone they trust. Keep that in mind when you see or hear negative comments about Donald Berwick.

Doc B.

My opinion is free.
Advice is worth exactly what you pay for it.

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End Of Life Discussion Is Not Health Care Rationing

The term ‘Death Panels’ has been thrown around since the first draft of the new health care bill emerged.  In that bill, section 1233 originally stated that Medicare beneficiaries were entitled to one visit with their primary care provider every five years to discuss end of life issues.  Not a bad idea but, honestly, every five years may mean that some people would never make it to their PCP for the discussion.

After an enormous wave of outrage over the idea of rationing and death panels emerged, the section was apparently scrapped.   Then, with the passage of the PPACA in the wee hours on a cold November Saturday night, it re-emerged, but with an annual option instead, as a Medicare benefit.  Beginning January 1, 2011, Medicare patients and their providers can sit down and talk with dignity, their individual thoughts about end of life issues, and the provider will be paid for such a discussion as part of the patient’s annual physical examination.

In the past, we providers more often than not have come face to face with this issue in hallway discussions, not with the patient but with their families.  And as you can imagine, families facing those issues with no clear guidance from the patient feel the full burden of making those life and death decisions when they and the patient are the most vulnerable.  The decision is an informed one but covered with layer upon layer of emotion and doubt, multiplied by the number of family members present.  Even if the patient had a discussion with their spouse or loved ones prior to the current critical illness, doubting Thomas’ in the family, some who haven’t seen dear “uncle John” in twenty or more years thrust a dagger of doubt and guilt, saying you’re just trying to kill him.  What a needless burden to leave to family and friends.

Consider that one third of all Medicare dollars are spent on chronic health care related expenses in the last two years of a person’s life.  Many of those dollars are spent on hospitalizations which merely prolong dying and not prolonging life.  And consider the concept of “quality of life”. Is it quality of life to lie in a hospital bed with a catheter in your bladder to drain urine,, a tube in your rectum to collect stool so the skin on your buttocks doesn’t break down into an open wound, an IV in your arm for antibiotics, sedatives, analgesics, amnestics, etc.,, a tube down your throat to breathe for you, hands and feet tied so you can’t pull out any of your tubes, lines or wires, another tube passed down through your nose to feed you?  All the while one slips in and out of consciousness as family and friends sit at the bedside, weeping and wringing their hands hoping for a full recovery.  If that’s your idea of quality of life, you can have it, at whatever cost to family, friends, Medicare, whomever.

In the best of worlds, all of us would have the discussion of what we, as patients and dignified human beings, would want in the event of critical or catastrophic illness.  We would write those thoughts and wishes down, sign it, have it notarized and kept with all of the other important papers we keep.  Having an end of life discussion is not rationing, but it is a very rational thing to do.

Be sure to have your end of life discussion and decide how, and with what dignity, your last days will be like before someone else decides for you.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

Addendum 3/22/2011

A recent post I read at the Health Care Blog caught my attention. It was looking at the new Medicare benefit allowing patients to discuss end of life issues with their physician and have the physician to be able to bill for that discussion. The article by David E. Williams entitled, here, here, here.

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Do You Love YOUR Ipad? Just Wait To See What’s Coming!

A recent article on The Health Care Blog titled “Doctors Love iPads. What Does it Mean? What Does it Mean?“, declared Apple the winner in the EHR/EMR world because it is the “#1 tech company in the world”.  Maybe.  But that also means that everyone else will be trying to knock the king of the hill off the top.  In much the same way that Apple was toppled from the top of the smartphone hill, they will be in a battle for market share of the ongoing tablet frenzy. In an article from CNN, author Adam Ostrow writes;

…one might jump to the conclusion that Apple has little to be worried about in the way of competitors to its iPad.

However, that would be a mistake.

While Apple sold nearly 15 million iPads in 2010 and closed the year with 75% market share in the tablet space, that was down from 95% in the third quarter of 2010, before the Galaxy Tab went on sale.

And regardless of whether or not the Galaxy Tab is a hit or a dud — Samsung claims its return rate is actually 2% — a slew of better Android devices are about to invade the market — not to mention offerings from other players including RIM and Palm.

“Also, let us not forget recent history. It was less than two years ago that pundits were beginning to suggest that Android was a failure. At the time, there were only two Android smartphones on the market, despite the dozens of partners that Google had announced at the launch of Android in late 2007.”

Gizmodo says: “If you consider where Android was when it started versus how far it’s advanced in 18 months with Android 2.2, you might get brain freeze.”

There is no reason to think that the 400 pound tech gorilla, known as Apple, won’t be under siege with its Ipad the way it was with its Iphone. As a reformed Iphone user myself, I can tell you that I am much happier with my Android product than I ever was with the Iphone. There are more hardware choices, frequent and easy to install software updates, many apps in the “market” that are either free or of low cost and the hardware all use blackberry compatible chargers, cables, etc. No need to pay extra for “proprietary” anything. Just go to any store and get whatever accessory you need at a competitive price.

And as the competitors take a greater share of the tablet market, all software vendors, including EHR/EMR, will be coming out with their products in an Android compatible format.

“If you build it they will come.”

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

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Are All Health Care Related Blogs Newsworthy?

On a recent visit to The Health Care Blog, I ran across a blog entry by Dr. Robert Wachter, the undisputed father of Hospitalists and Hospitalist Medicine.  In this most recent post he references an article by a colleague cautioning the potential dangers of CT scans, at least the unnecessary ones, which can, in and of themselves, cause cancer.  Because of the seriousness of the conclusions drawn by the article and the blog post, no less than four (and now five) articles/blogs have referenced that blog in their own articles or blogs.  An excellent comment was posted soon after the original entry by Dr. James A. Brink, Member of the American College of Radiology ,and their Chair for the Commission on Body Imaging.  His comment was informative and very well referenced.  But, it was also largely ignored by the remainder of the commenters at the site.  Dr. Brink, in essence, agreed with Dr. Wachter, in that no test, regardless of type should be ordered if unnecessary.

Despite Dr. Brink’s thoughtful comments, references and concise writing, including his conclusion, what everyone else will likely read is the more sensational article or blog which will likely raise fear in the hearts of the reader; “There is a strong biologic counterargument to the notion that low levels of low-LET radiation are carcinogenic (2, 5). Tubiana et al (5) report, “there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv.” As these radiation doses are grossly in excess of doses delivered with a single 10 mSv CT scan, it is imprudent for those in group 1 to base medical decision-making solely on these risk estimates. Rather, practitioners should operate under the premise of group 2. As Smith-Bindman advocates (6), “we must ensure that patients undergoing CT receive the minimum radiation dose possible to produce a medical benefit.” One of the best ways of reducing radiation is to assure the appropriateness of the ordered test and to eliminate tests that are not indicated. Of greatest concern is the possibility that patients in need of medical imaging may be denied the benefits of modern health care owing to an unproven and uncertain risk of cancer.”

It is unfortunate that the power of the internet, blogs and ready access articles, also make for the presentation of one sided discussions, leaving excellent comments like this one behind.  The goal seems to be, just like in print news, to be the first with “breaking news.”  Sell the papers with a sensational story on page one; print the retraction on page 30.  With the web, you really have to dig and check all the references, comments, blogs, etc., to get at the true story.  You can’t simply take anything at face value.

My take away from the original article, blog post and comment is;  There is a risk associated with the radiation exposure from any imaging procedure. The exact amount of that risk and any future consequences is likely small, but potentially real.  Order those tests which are necessary to treat your patient.  If it isn’t necessary, it isn’t worth the risk, no matter how small.

Doc B.

My opinion is free.

Advice is worth exactly what you pay for it.

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