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Will Rationing Care Become Part Of Reform?

The impetus for government to control healthcare costs should be obvious to us all and intervention now appears unavoidable.  Two issues will soon come to light: the exorbitant costs to fight disease at the end of life, often when the approach of death is barely retarded and the wide disparity in costs between different geographical regions of our country for similarly aged patients.  It is estimated that 27% of Medicare’s annual $327 billion budget – one fourth of its operating budget – goes to care for patients in their final year of life while Medicare averages $20,000 more dollars for patients in Manhattan than in some rural areas of our country.

With this in mind, I share a deep concern with many of my colleagues that part of the healthcare reform debate will turn to the rationing of healthcare. This appears a logical progression from the proposed establishment of guidelines and advisory committees currently allowed for in the Health Reform bill already passed. The question as to who should receive possibly futile care is not clear, rather it is fraught with complexity, often relying as much on evidence-based research as it is on assessments made by the medical practitioner in light of the relationship the doctor has with the patient.

At the heart of the rationing issue are two, often warring, sides of medicine:  art and science. Medicine began as an art thousands of years ago, and moved more towards science when, in Ancient Greece, Hippocrates taught physicians to observe the results of their treatments and make adjustments. However, art should not be removed from medicine, for this is where the doctor-patient relationship comes to play, serving as a cornerstone of effective and humane medicine.  It would be impossible for physicians to uphold the noble traditions of the medical profession, adequately serve society, or preserve the dignity of human life if doctors were to become, purely, scientists.  As long as we are treating people, medicine should never become solely a science.

Rationing, however, would be based purely on science, completely devoid of any art and, I believe, serve as a blow against the sanctity of the medical profession.  Setting up rationing guidelines as they pertain to the end of life would circumvent patient’s trust in the doctor-patient relationship and risk the very soul of medicine by negating the importance of the doctor-patient relationship. Evidence-based recommendations can and should be set forth pertaining to protocols for offering treatments as the end of life seems near.  This would likely reduce some of the high and disparate costs in caring for our elders; however, it is important to consider the input of a doctor aware of the needs and desires of his patient.

I come to this argument both as a physician and from personal experience. Several years ago, my 75 year old father was hospitalized four times over five months.  His medical team, led by a kind and experienced surgeon, unburdened by guidelines or anyone else’s recommendations, gave him a chance despite long odds against his survival.  Medically speaking, I am still surprised he made it out of the hospital to live a normal life again.  During the subsequent five years, he has welcomed three grandchildren into our family; I would challenge anyone to assign a monetary value for that life experience.  My professional and personal experience leaves me quite sure that he would have fallen a victim of any rationing guidelines that could ever exist.

In short, as the average life span increases most of us nurture the hope to live longer, cheering as science opens the door to seemingly innumerable advancements. Yet are we, as a society, equipped, whether it be emotionally or fiscally, to handle the decisions that must be made as the end of life draws near? More importantly, should government be allowed to set up strict guidelines without an active debate from physicians and patients?  These guidelines could sacrifice what has long been and should still remain most important to healthcare: the doctor-patient relationship.

Healthcare Reform: Then (1994) And Now (2009)

DrRich has been around long enough to remember the sequence of events that accompanied the collapse of healthcare reform under the Clintons in 1993 – 1994.  (Heck, he has been around long enough to remember Nixon’s plans for healthcare reform, which drowned in Watergate.) When President Clinton was inaugurated, everyone agreed that the American healthcare system was in a state of crisis (e.g., spending levels could not be sustained, there were too many uninsured, there was too much waste and inefficiency, etc., etc.), and that the time for fundamental reform had finally arrived. We had a fresh, dynamic, young President with new ideas and with a solid majority in both houses of Congress, and he was armed with polls showing that the people were in favor of fundamental reform.

Accordingly, when Mrs. Clinton put together her working groups to devise a reform plan, she initially had the enthusiastic participation of numerous interest groups within the healthcare industry – notably including the insurance companies, physician groups, and drug and medical device companies.

But when she finally produced her plan – a disturbingly heavy tome filled with frightening details – everybody was horrified with at least some of the stuff they found there. Most of the big interest groups turned on her – most notably, the insurance industry, which then launched the famous Harry and Louise commercials to scare the people about government healthcare. The people, now duly scared, called their congresspersons, who (despite the Democrat majority) ended up sending Mrs. Clinton’s healthcare reform to a crushing and humiliating defeat. And the Republicans were able to capitalize on the “near miss” of the Clinton’s brazen attempt at socialism, and in 1994 ushered in 12 years of a Republican majority in both houses of Congress.

Obviously, for those Republicans and other observers who abhor Mr. Obama’s plans for healthcare reform, it is relatively easy to see parallels between what happened in the early 1990s, and what appears to be shaping up now. Those parallels, and the subsequent ignominious defeat of the Clinton plan, are the only things keeping these sorry individuals from donning sackcloth, heaping ashes upon their heads, and engaging in public self-flagellation.

So, perhaps, for such outsiders the spectacle of the major private healthcare interests this week throwing in with the Obama administration will be seen as one more sign from the gods that the parallels of 1994 are falling into place.

But they are wrong.

There are at least three important differences between the enthusiastic participation of private interests in Mrs. Clinton’s working groups on healthcare reform, and the action taken this week by representatives of insurers, doctors, drug companies, hospitals, and medical device manufacturers to pledge their undying support for President Obama’s efforts at healthcare reform.

First, in 1993 the private interests were powerful and confident. They participated in the process because they felt they could control it. It turned out they were wrong, of course – the only one who has been able to out-maneuver the Clintons is Mr. Obama – and the plan Mrs. Clinton finally produced (despite all the “input” from diverse private interests) really was a blueprint for a full government takeover of healthcare, all spelled out and wrapped with a bow.  But because the private interests were powerful and confident in those days, once they figured out what the Clintons actually had in mind they were able to scuttle healthcare reform entirely.

In contrast, today the private interests have come to the table not out of strength, but out of weakness. They come not as partners in negotiation, but as vanquished foes. They come to Obama as the Carthaginians came to the Romans after the second Punic war, suing for peace, begging for terms, offering massive tribute (in this case, $2 trillion) in exchange for being permitted to eke out a meager survival, at the edge of the desert. (DrRich wonders whether the insurance companies and their friends remember the third Punic war.  Surely they must know that somewhere in Congress is another Cato the Elder, ending every speech with the words, “The insurance industry must be destroyed,” and that at some point their remaining, puny base of operation will be completely sacked, and their mission statements sown with salt.)

Second, whereas Mrs. Clinton was a major policy wonk who reveled in providing a fully-fleshed-out and exquisitely detailed set of plans for healthcare reform – thus giving her foes sufficient ammunition not only to defeat her reform plan, but also to banish the Democratic Party to the wilderness for three election cycles – Mr. Obama is not. His reform plan will be bare-bones – merely an outline, more-or-less a statement of principles. There will be nothing to attack, since there will be no details, and little will be spelled out. (Implementing the plan will be left to unelected bureaucrats and regulators, who are always happy to produce prodigious amounts of undecipherable and self-contradictory detail.) This time, at least prior to its actual implementation, critics of the reform plan will be left trying to attack a phantom.

And third, this time there is no Plan B.

In 1994, once the private interests had scuttled the Clinton healthcare plan, they immediately offered an alternative. They came to us and they said: “Citizens!  We have just now dodged a bullet! Thanks to us insurance companies, doctors, drug companies and other patriots, the frightening socialist machinations of the Clintons have been defeated, and the Evil Ones have been reduced to embracing our agenda of tax reform and welfare reform as if it were their own.  But where does this leave our healthcare system? We stand now between Scylla and Charybdis, between the spectre of socialized healthcare on one hand, and the continued profligacy of traditional fee-for-service on the other, and we cannot survive either.

“But here,” they continued, “is a third way. A painless way, an American way, based on the principles of managed care, open markets, and free enterprise. Let healthcare become a business, like any other business, and let the natural efficiencies of the marketplace find ways to cut costs and improve quality, and with minimal government intervention.”

And thus we were launched into an era of managed care run by HMOs and other similar creatures of the insurance industry. And over the past 15 years, while managed care has utterly failed to produce any of the things it promised, it has not been for a lack of trying. They indeed have tried numerous things to control spending, from the reasonable-sounding to the absurd to the frankly murderous, and despite all their strenuous efforts the healthcare system remains a morass of confusion, waste, and inefficiency, and its costs are many times what they were in 1994.

To say it another way, the private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do.

And that’s why they have now fully abandoned their old allies, the Republicans (who are off somewhere – one knows not where – muttering to each other about the efficiencies of the marketplace, and wondering why nobody is listening to them). The last thing the insurance industry wants to hear today is that the burden of figuring out how to control healthcare costs belongs to them. They’ve tried everything they know and have failed, and they are desperately seeking terms for surrender.

So there is no Plan B this time. As of this week, the private interests have formally and publicly admitted they don’t have a clue. They’re throwing in with President Obama, despite the fact that they have no leverage with him whatsoever, not because they believe in his reform plans (which have not even been described in their most skeletal form), but because there is no place else for them to go.

And so, the last obstruction to healthcare reform has been removed. The path – the only path – is clear. If we fail to get comprehensive healthcare reform now, it can only be for one reason. It can only be because Mr. Obama and the Democrats, looking down that wide open road, will be unable to avoid seeing where it leads, and will decide that they do not want to be the administration or the party that finally has to begin saying the “R” word in public.

To turn away from healthcare reform now, when the way seems so clear, would be a crushing blow to them, and would likely not be politically survivable. But to go on will likely force them to begin speaking a truth – that rationing is unavoidable – whose name is more taboo than ever was the name of Yahweh. And every high priest of the ruling class knows that even hinting about healthcare rationing is political suicide.

But still, there it is. There is no Plan B.

Talk about Sylla and Charybdis.

*This blog post was originally published at The Covert Rationing Blog*

Healthcare Rationing: Necessary or Evil?

I met a urologist from another city recently.  Since it had been a much discussed issue recently, I asked him what he thought about PSA testing. His answer was immediate.

“I think PSA testing has been proven to save lives, and I have no doubt it should be done routinely.”

When I mentioned the recent recommendation that prostate cancer screening be stopped after a man reaches 70, his faced turned red.  “That report is clearly an attempt by the liberal media to set the stage for rationing of healthcare.  It was a flawed study and should not be taken as the final say on the matter.”  He went on to recount cases of otherwise healthy 80 year-old men who developed high-grade prostate cancer, suffered, and died.

I chose not to debate him on the subject, but did point out that his view was that of one who sees the worst of the worst.  I personally can recall less than ten patients who died of prostate cancer in the fifteen years I have practiced.  My view is one that sees a non-diseased general public, and not worst-case scenarios.  I also didn’t point out that even the American Cancer Society stopped pushing the test and states, and does not think as highly of the evidence as he does: “Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives.” (1).

But I digress.  What really struck me in the discussion was the way he pulled out the idea of rationing as the end-all hell for American healthcare.  It is regularly used as a scare tactic for those who advocate a “free market approach” to healthcare.  They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis.  Rationing healthcare seems a universal evil, and any step that is made toward controlling cost is felt by some to be a push of the agenda of the Obama administration toward universal health coverage and ultimately rationing.

So what exactly is so bad about rationing?  The word itself refers to an individual being given a set amount of a limited resource, above which none will be available.  In healthcare, the idea is that each American is given only a set amount of coverage for care and above that they are left to fend for themselves.  Those who are either go over their limit or are felt to have a less legitimate claim on a scarce resource will be denied it.  This is especially scary for those who are the high-utilizers (the uninsurable that I have discussed previously), as they will use up their ration cards much faster than others.  I certainly understand this fear.

But are all limitations put on care really a step toward rationing?  Are limits put on care a bad thing?  The answer to that is simple:  DUH!  Of course not!  Of course there need to be limits on care!  Without control over what is paid for, the system will fall apart.  Here’s why:

  1. Limited Resources – Not only are our resources limited, they need shrinking.  The overall cost of our system is very high and has to be controlled somehow.  Different interests are competing for resources, and by definition whoever doesn’t win, doesn’t get paid.  This means that someone needs to prioritize what is a necessity and what is not.
  2. Lack of personal culpability by patients – with both privately and publicly funded insurance, the actual cost to the patient is defrayed.  They are not harmed by unnecessary spending, so they don’t try to control it.  Only uninsured patients are painfully aware of the cost of unnecessry tests.
  3. Lack of personal culpability by doctors – If I order an unnecessary test or expensive drug, I am not harmed by the waste.  For example, it is common practice by emergency physicians in our area to get a chest x-ray on children with fever.  Most of this is related to defensive medicine which is understandable in the ER, but clinically the test is often not warranted.  Yet the emergency physicians are not really affected by this waste, and the hospital and radiologists are actually rewarded by it if the insurance company pays for it (which they do).
  4. Incentives for other parties – As I just said, hospitals and radiologists have incentives to have wasteful procedures done.  The urologist I spoke to has a huge financial stake in the continuation of PSA testing, as it generates enormous business for him.  Drug companies want us to order their more expensive drugs than the generic alternatives.  This doesn’t mean any of them are wrong, but they sure as heck won’t fight waste if it harms them financially to do so.

When I was a physician starting out, the insurance companies would pay for pretty much any drug I prescribed.  At that time there were very expensive branded anti-inflamatory drugs that were aggressively pushed by the drug companies.  When the first drug formulary came around, the first thing that happened was that they forced me to use generic drugs of this type.  Before, there was no reason not to prescribe a brand, I had samples, and they were a tiny bit more convenient.  But when I changed there was really no negative effect on my patients.

One of our local hospitals just built a huge new cardiac center.  Statistically, our area is a very high-consumer of coronary artery stents compared to the national average.  Yet there are many cases in which an asymptomatic person will get a stent placed simply because they have abnormalities on their cardiac catheterization.  Logically this may make sense, but the data do not suggest that these people are helped at all.  Do you think that the hospital wants these procedures halted?  Do you think the cardiologists do?  Yet if they are truly unnecessary, shouldn’t they be stopped?  Couldn’t the $200 million they spent on their state-of-the-art facility be used in better ways?  Someone has to be looking at this and making sure the money spent is not wasted.

Without cost control a business will fail, and the same goes for our system.  Yet any suggestion at the elimination of clinically questionable procedures is met with cries of rationing.  Right now we are not at the point of rationing, and the act of trying to control cost by eliminating unnecessary procedures does not necessarily imply that the end goal is rationing.  The end goal is to spend money on necessary procedures instead of waste.  I sincerely doubt there is a left-wing conspiracy to push us to deny care where it is needed.  I doubt that the American Cancer Society is in favor of rationing.

Let’s just spend our money wisely.  It’s just common sense; not an evil plot.

*This blog post was originally published at Musings of a Distractible Mind*

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