Hat tip to Kevin M.D. for calling my attention to “The Covert Rationing Blog,” where Dr. Rich offers a concise summary of the dilemma we face as we move toward a consensus that healthcare is not a privilege, but something that every human being should have. (One can call that a “right” or a “moral obligation that a civilized society has to provide healthcare to everyone”). The point Dr. Rich is making is that once you decide everyone deserves health care, the question is “how much care.” As he puts it:
“Exactly how much healthcare are you entitled to if you have a right to healthcare? Do you have a right to certain specified healthcare services, to a certain dollar amount of healthcare per year or per lifetime, to whatever healthcare it takes to achieve perfect health, or to some other limit or non-limit?
“The question of limits (whether we should have them or not, and what should they be) has been a central theme of this blog and of DrRich’s book. To reiterate the fundamental problem: 1) In America we believe that it is wrong to limit healthcare in any way, that everyone is entitled to the very best healthcare, that any bit of healthcare that offers even a small potential of benefit should be provided, and that death itself is merely a manifestation of insufficient research (or actionable incompetence, or systematic discrimination against the unwealthy, or corporate greed). 2) But against that closely held belief, we must balance the unremitting law of economics which tells us that there is simply not enough money in the known universe to buy all the healthcare that might potentially offer some small amount of benefit to every person. Healthcare spending has to be limited, or it will become a fiscal black hole.”
Dr. Rich is correct on all counts. Our American love affair with medicine—and in particular, medical technology—is all tied up with our fear of death, and a feeling in some quarters, that “American optimism” demands that to strive for immortality. We put such emphasis on the individual, and the individual ego; how can we accept that, someday, it will be extinguished? ( I’ll always remember the doctor who told me, in an interview, “Of course, one day, most people will die.” I wonder who he was excluding from “most people”? )
In my recent post on medical technology driving health care costs, I suggested that we need to begin setting limits on that technology. This is especially true if we are aiming for universal coverage.
Here we need to recognize that covering everyone will cost more—much more. Some well-meaning reformers have suggested that once everyone has access to care, we will save money because those who are now uninsured or underinsured will receive preventive care. The theory is that, today, the uninsured wind up in the hospital—where they receive very expensive care—because they didn’t get needed care in a timely fashion. I should acknowledge that in the past, I have made that very argument.
But sometime over the past year or so, I have come to realize the ugly truth: the uninsured die sooner than the rest of us. By leaving a significant portion of the population poor, and uninsured, we save money.
As the new Synthesis Project by the Robert Wood Johnson Foundation, “High and Rising Health Care Costs: Demystifying Health Care Spending,” reveals, studies consistently show that when a large portion of the previously uninsured population becomes insured, total health care spending rises by 10 to 13 percent.
Indeed, this report by the Center for Healthcare Systems Change (HSC) shows that, over the past decade, the decline in the percentage of Americans who have insurance has slowed the rate of health spending growth. If everyone had been insured, our national health care bill would be even higher.
As Dr. Rich puts it, “steadily increasing the number of uninsured Americans has become perhaps our most effective mechanism of covert rationing. This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits.”
This is because while preventive care will keep some previously uninsured patients out of the hospital, they also will live long enough to fall victim to very expensive diseases like Alzheimer’s, and certain cancers. Moreover, the previously uninsured, like the rest of us, will be overtreated. Unless universal coverage includes some very intelligent rationing, that many more people will receive unnecessary tests and scans, leading to unnecessary procedures.
This, of course, is not a reason to leave a large segment of the population uninsured.
But it is a reason to take Dr. Rich’s argument seriously. Now that we seem to be reaching agreement that we no longer want to ration care according to ability to pay, we will have to begin discussing how to ration care some other way.
It seems reasonable to begin by refusing to pay for treatments that are only marginally effective, giving the average patient only a few extra months of poor quality life. But if “on average” patients live only a few months longer, that means that a few patients will live nine months longer. And we cannot know we they will be. Yet our resources are finite.
It strikes me that before we pour vast sums into customized medical care based on genome research, we might ask whether we, as a society, will be able to afford such care. Or will this be medicine only for the wealthiest few?
Perhaps rather than focusing on technological progress, we should focus on harnessing the technology that we have now so that we can understand it better, and use it more efficiently, for the benefit of the population as a whole. After all, what is the point of universal coverage if we cannot afford to provide universal care?
All of this winds back to our vain effort to somehow “beat death.” We keep pushing the envelope, in hopes of living longer. But living longer only means dying of something else. And, too often, it means that the body outlives the mind. Wouldn’t it be better to aim for a higher quality of life, for all of us, for eight decades, or perhaps nine—rather than striving to see how many of us can totter over the finish line at 115?
There is a model for “how much” it can be found in the special education legislation. Children with disabilities cost more to educate than the rest and they will provide less economic benefit later when they move into the workforce (if able). Nevertheless schools systems have established a balance which works fairly well except for the most extreme cases.
“Universal” care will also establish guidelines in the US just as has happened elsewhere. The amount to be spent may be more than in other countries and may lead to a higher proportion of pointless spending, but it won’t be infinite.
I also believe that medical costs will come down not continue to increase. In fact I think if the value of the treatments included the subsequent economic benefits to society from a healthier patient we would see that net costs have not been rising as fast as the raw data seems to indicate.
I’ve cited the example of heart bypass surgery allowing people to return to work vs those who became permanent invalids in earlier times. How much have Bill Clinton, Larry King and Dave Letterman paid in taxes and how much have they paid in salaries to their staffs since their operations? Where is this offset against the cost of treatment?
In addition medical technology gets cheaper over time just as does other types of high tech inventions. We may be experiencing a period of over adoption of new devices, just as with other crazes (like CB radios), but this will taper off.
There is already a pall hanging over the drug industry as the number of potential new blockbuster drugs declines and existing ones go off patent.
I think extrapolating from the past 20-30 years is not wise, just look at the projections about the stock and housing markets. As Herb Stein famously said: “If something cannot go on forever, it will stop.”
I think a profitable direction for discussion would be how to plan for a comprehensive health system assuming that the most outrageous faults of the present arrangement will be brought under control.
“Perhaps rather than focusing on technological progress, we should focus on harnessing the technology that we have now so that we can understand it better, and use it more efficiently, for the benefit of the population as a whole. After all, what is the point of universal coverage if we cannot afford to provide universal care?”
there are a lot of people, many of them sympathetic, who will vehemently disagree with this idea. Any individual afflicted with disease for which there is no cure (or group representing such disease) will rail against the “let’s stop focusing on technological progress” with all their might. Can you blame them?
I think there are a lot of loud, passionate, and sympathetic voices that will make it very hard to push this idea forward in an explicit way. (thus the covert rationing Dr. Rich details on his blog.)
I recognize that some day we have to start deciding how much care is prudent, but it seems silly to do that before we fix the other parts of the system that are wasting dollars on make-work efforts, like the insurance bureaucracy that is draining 31% of healthcare costs needlessly. Or the over-utilization by doctors simply to drive up profits. And the massive costs resulting from ineffective IT.
Let’s get the US at the top of the care level rather than 37th in the world.
Then let’s tackle the rationing. If it’s my loved one we don’t ration; if it’s your loved one we do. That’s what it will come down to. It is not going to be a pretty picture.
But before we get there let’s eliminate Viagra and other stupid things for coverage. Maybe we could start paying families cash dollars if they let their sick ones just bite the dust.
I’ve got some in-laws to volunteer. 🙂
One of my longheld arguments is that prolonging death is actually inhumane and even cruel. That renders it “worse” than denial or reduction of medical care or rationing.
But the fear of death is SO pervasive in our young “can do” nation and the ethic of US medicine “defeating” death is so ingrained that I do not expect my views to carry the day soon?
When we as citizens and health care providers stop viewing death as a disease to be “treated” or worse “cured” we will have come a long way toward individual and cultural maturation.
Don’t hold your breath(no pun intended)
Dr. Rick Lippin
Southampton,Pa
At 71, Rick, I’m hoping I won’t be around when those kind of decisions are made.
Robert, Jack, pcb and Rick-Thanks for your comments.
Rick,
I agree completely.
The perasive fear of death is, I think, linked to our youth as a nation–and our immaturity.
European culture is, by and large, far more philsophical about death. (This includes the English).
This isn’t to say that they don’t grieve, but they don’t try to hold on to the last inch– or torture others by prolonging their deaths.
As a group of British medical students told Dr. Steve Schroeder: “You people just don’t know when to stop.”
pcb–Yes, there will always be patient’s groups calling for progress. But sometimes the advocates are their own worst enemy, encouraging and even demanding treatmens (like bone marrow transplants for breast cancer patients) that did no good-and put many, many women through a harrowing experience, with no benefit.)
Too often advocacy groups insist that their Must be a cure for a particular disease, when there just isn’t. And we’re not close to finding one.
I’m very, very sympathetic to parents of dying children who are desperate to find help for their illnesses.
But as a pediatric oncologist at M.A. Anderson pointed out to me, we spend far less money on research into cancers that kill children than into cancers that kill middle-aged adults.
Why? Kids don’t have any power, and their parents are generally too busy–and too distraught –to form advocacy groups to lobby Washington.
And, as this oncologist put it: “We call ourselves a nation that loves children.”
As with everything else in our healthcare system, money and power determines where we put our health care dollars. We spend the most on diseases that affluent middle-aged men are most afraid of: cancer and heart disease.
Instead, we should be spending most in areas where there is some hope of progress.
When it comes to heart disease recent research shows that we have reached a point of diminishing returns:–we keep spending more and more developing new technologies, different stents, etc., and we’re no longer reducing mortalities.
The most successful “new” technology has been aspirin.
Orphan diseases–that afflict very small groups of people–can be heart-breaking because they just don’t attract much interest from people trying to make money on medicine.
But very often, patients (or parents of young patients) will find one or two or three scientists who are interested in the disease for purely scientific reasons– and can help.
It’s the large scale efforts–like trying to find a cure for cancer–that have failed for decades, in large part because there is too much competition (for the money and the glory) and too little collaboration.
We have made good progress with some cancers, not with others. And I think at this point we realize it is not one disease with one cure.
Meanwhile,Alzheimer’s is a scourge that will kill more of us as we live longer and we’d all like to see some progress. I don’t know enough about the research to know where to put the money.
But ultimately, we need to think collectively about this. Not in terms of “my disease” but rather “our” collective health–and the health of the nation’s children.
How can we best spend health care dollars to, first, keep children healthy, and secondly, try to improve the quality of life for as many of us as possible? This means spending in areas where we are making progress — and, perhaps most importantly, spending more on public health measures.
In addition we need to spend more on “comfort” (i.e. palliative care and hospice care) rather than futile attempts to cure.
Rick is right. Death is not the enemy. When it comes to how we treat the dying, we are the enemy
Finally, pcb, you write: “Any individual afflicted with disease for which there is no cure (or group representing such disease) will rail against the “let’s stop focusing on technological progress” with all their might. Can you blame them? ”
Unless they are railing against a disease killing a child, or a very, very young person who has not yet had a chance to live–yes, I’m afraid I can blame them.
Though “blame” is a little harsh. But I wish they would grow up.
Once you reach middle-age, there is such a thing as facing death with dignity–accepting that one day, we will all die. And if we don’t die of this disease, we may die of something much worse.
I have seen people accept death with patience and courage. That is a “good death.” It’s not always possible, (and I have no idea whether I’ll be up to it), but it’s certainly something to strive for.
Jack–
I absolutely agree that there are things to fix in the system–particuarly wringing out wasteful ineffective treatment–before we start “rationing.”
But I’m afraid that what you and I would call eliminating overtreatment, others would call “rationing.” This is because they cannot accept the fact that “cures” that might give you another 2 months really aren’t cures.
Finally, at some point in the future, we really are going to have to talk about saying “no” to treatments that are exorbitantly expensive and of small benefit.
So we should begin the conversation now, laying the groundwork for being able to make rational, compassionate decisions 10 years from now.
I don’t think rationing has to be ugly. Especially if we, as a culture, can begin to understand that “death with dignity” also means accept the inevitablity of death.
Robert–
I agree completely– “If somethign cannot go on forever, it will stop.”
I, too, very much doubt that health care spending will ever reach 25 percent of GDP.
But I am very afraid that the way we will bring a halt to runaway health care inflation by accepting a harsh two or three tier system. In the top tier, the wealthiest , most powerful 5 percent –maybe 10 percent– will receive the most advanced hi-tech care, whatever the cost–and they will be treated by the “best” doctors at the “best” hospitals.
The vast majority of us will receive something closer to today’s Medicaid.
This is how many health care economists see things playing out. , unless we rein in the over-priced medical technologiest that are driving health care inflation. (Scroll down to my earlier post on what is driving health care costs.)
Medical technology, unlike technologies in other sectors of the economy, does Not become less expensive over time. It almost always becomes more expensive (as we add bells and whistles.) This is because we, as a nation, believe that “nothing is too much to spend on healthcare,” ignoring the fact that so much care provides relatively little benefit.
Finally, while other nations have established equitable guidelines for universal coverage, we are
not like other nations. We are much more divided by class and wealth. And as a result, we are more likely to accept a sharply tiered system.
This doesn’t happen–but it could.
The parallel to education is relevant: look at the difference in spending on public schools in our inner cities and public schools in our most affluent suburbs . . .
How do you decide which life-saving techniques are appropriate, and which should be eliminated? While I do agree with you that our country spends far too much time and effort trying to extend people’s lives (sometimes hopelessly), where do you draw that line? Some people simply need medications to keep them alive, while others require more expensive equipment and treatments. You certainly can’t put a monetary value on “life,” so how do you make that decision? I think we’ve reached a point where we can’t really go back. We’ve let the secret out of the bag – we have techniques that will keep you alive. People know that, and they expect that. And we’ll have a heck of a time taking that away from them. We might just have to reach a point of no return – where the health care system is so expensive, so out of control, and so ridiculous that we just tear it down and build it back up from scratch. Until then, how do you make drastic changes like this? We’re having enough trouble getting our health insurance prices to regulate!
Krista–
We already ration care–based on the patient’s ability to pay.
We just don’t talk about it. And most patients don’t realize that it is happening.
For example, if a doctor knows of a very expensive drug–and also knows that the patient’s insurance won’t cover it (or the patient doesn’t have insurance) –and the patient is not wealthy enough to pay for it out-of-pocket, he may just not mention the drug.
Some doctors argue in favor of “bed-side rationing” as a way to help contain sky-rocketing health care costs.
Here’s an example: Treatment A works 95 percent of the time, Treatment B works 75 percent of the time–and costs 1/10 as much.
A doctor concerned about conserving resources for society as a whole may
well prescribe treatment B–even though it woudld be in the best intersests of the indivdiual patient to prescribe the more expensive treatment A.
This is controversial. Some physicians believe that the doctor should always do what is best for the individual patient. Other doctors believe that physicians have a responsibility to think of society as a whole. If they waste resources by picking exorbitantly expensive treatments like treatment A —when treatment B will probably do the job–healthcare will only become more and more expensive for all of us.
The Supreme Court has ruled in favor of rationing care. A 2000
article in the Journal of the American Medical Association explains:
“With stunning candor, the Court proclaimed that health care rationing is not only routine in the United States but also a matter of national policy.”
This was a unanimous decision.
The JAMA article (which is critical of the ruling) concludes: “Whatever its shortcomings, the Supreme Court’s opinion in Pegram was an exercise in moral honesty. The justices said bluntly that HMOs control costs by rationing care, that Congress approved of this when it passed the 1973 HMO Act, and that physicians paid to practice parsimoniously wear 2 hats, as coverage decision makers and clinical caretakers. But the Court declined to construe ERISA, the ambiguous statute at issue, to require limits on physicians’ financial rewards for frugality.
“By breaking the taboo against talk about rationing, the Court’s unanimous ruling summoned Americans to confront the conflict between health care cost consciousness and insistence, when ill, on all that medicine might offer.”
I agree: we should talk openly about rationing.
It is happening–and will continue to happen–even if we pretend it doesn’t.
The fact is that resources are finite. Hospitals cannot afford to provide you with extraordinarily expensive care if you cannot afford to pay for it. Sometimes hospitals just can’t “eat the cost.”
Part of the problem is that many drugs and other treatments are grossly over-priced. As I explained in my recent post, we pay far more than other countries for everything– drugs, devices, specialists.
Another part of the problem is that many very expensive treatments are of marginal value–for instance, they may give the average patient only an extra two months.
We, as a society, really cannot afford to pay for marginally beneficial treatments.
This is why medical ethicists and physicians need to begin educating the public about the fact that there have to be limits.
And medical schools need to do a much better job of educating medical students on how to care for dying patients. Doctors need to be taught, from the beginning, that death is not necessarily the enemy.
Unnecessary, pointless suffering is the enenmy.
Finally, an intelligent and realistic discussion of the cost of medical care.
Of course expanded coverage costs more. Most of the things that people are treated for are not immediately life threatening and many have nothing to do with longevity.
The most cost effective thing we could do to DECREASE Medicare costs (and the total cost of health care over a persons life span) is to encourage people to smoke. Yes, they would die sooner (7 years on average) but they would consume significantly fewer health care resources during their life. It costs much less (medical expenditures) over the course of a persons life when a smoker dies of a heart attack or lung cncer in their 60’s than if they live into their 80’s with the last several years spent in a nursing home.
I am not advocating smoking, just pointing out that keeping people alive longer is more expensive.
As far as I can see, the only rational way for us to control health care costs is by rationing. The system that was adopted in Oregon years ago (and subsequently repealed) was the only intelligent approach to this system I have heard of in this country.
I am also confident that the people of the US don’t want rationing (or at least something that is explicitly stated to be or can be recognized as rationing) and that neither party has the guts to tackle the problem head on.
To make and analogy, the US is like a family that is spending too much on food. The family is buying potatoes, vegetables, Champagne and Caviar. The government approach to control spending is to reduce expenditures on everything by 10%. The intelligent approach is to drastically reduce spending on Caviar and Champagne.
I have a great deal of confidence that the government does not have the courage or wisdom to do the smart thing.
Just a thought. One way to look at the right to health care is to think about the way we regard other rights, like the right to education or free speech.
The right to education does not promise a seat in Harvard, nor does the right to free speech promise 30 minutes on TV.
In trying to define the limits of healthcare maybe we should implement the comparative effectiveness
program frquently mentioned and pair it with cost criteria.
I would like to offer a few thoughts on this.
First, as I’ve said before, I strongly support comparative effectiveness research. I also think we need to go a step further and embrace cost-effectiveness in our payment decisions. I think we could learn a lot from the UK’s approach which uses QALY metrics in helping to decide whether or not to cover and pay for new (and existing) drugs, devices, tests, and surgical procedures. I think this approach makes especially good sense in assessing new very expensive specialty drugs to treat cancer, MS and other conditions. According to the executive in charge of Walgreen’s specialty drug business, fully half of all new specialty drugs in the development pipeline are focused on treating cancer. That said, I also think it is appropriate to assign some value for new drugs and surgical procedures that offer the patient shorter treatment times, fewer and less severe side effects and quicker recoveries even if they don’t extend life beyond what was previously available. As a society, we need to learn how to just say NO to expensive treatments, but only CMS has the moral authority to do that. People who want such treatments will have to self-pay. While the wealthy could afford to do that and most of the rest of us couldn’t, nobody every said that life was completely fair. Resources are finite and we have to draw the line somewhere. For myself, I would be perfectly happy and willing to live under such a system.
As I’ve also said many times before, I think we need to aggressively try to increase the use of living wills and advance directives so people, especially the elderly, can make clear what treatments they want and don’t want as the end of life approaches. We also need registries or some other mechanism to assure that these documents are available to hospitals, doctors, and family members when needed in case the patient can no longer communicate.
If we eventually shift to taxpayer financing for health insurance, I think it would be extremely useful, at least if we are interested in efficient resource allocation, to have a dedicated tax that is highly visible and transparent so everyone knows how much they are paying for health insurance and healthcare from both a system and an individual perspective. While I know that Dr. Ezkiel Emanuel proposed a 10% Value Added Tax to finance his voucher approach, my personal preference is a payroll tax, though a supplemental value added tax might be useful to cover those who are not in the workforce including the unemployed, retirees, and children. A payroll tax could even be scaled to range from zero on, say, the first $25,000 of income for a family to 5% on the next $25,000, and 15% on wages above $50,000, perhaps up to some cap. There would also need to be integration with the income tax to make sure that wage earners are not significantly overtaxed relative to those who earn their income from interest, dividends, capital gains, rent, and other non-wage sources.
Legacy Flyer, Joan and Barry–
Thanks for your coments.
Legacy Flyer– the analogy to champagne and caviar is a good one. We really don’t need the excess in our system. We may like it
(Americans love the idea of
all of that gleaming technologoy–“Sputnik medicine”) and it may make us think we’re safer –but much of it is providing minimal, if any benefit.
However, I wouldn’t be quite so cynical that the govt doesn’t have “the courage or the wisdom to do the right thing.”
Though we have endured many years of bad government, history tells us that governement can do things that are wise and courageous. On domestic policy, LBJ’s administration did very well. Civil rights, Medicare and Medicaid . . .these things took intelligence and guts.
If course LBJ had to drag much of the country along, kicking and screaming, as did FDR.
There have been other high points — in state government and local govt as well as federal. The state and local governements I follow most closely are NY and NJ.
On the whole, Bloomberg has done a very good job in NY (though his school chancellor has not) and Corzine is doing the best he can in New Jersey. (In a state where people drive so poorly, how can you hope to govern them in a rational way?)
Joan–
I can’t quite agree with the analogy to the right to education or the right to free speech.
Not everyone would benefit from–or enjoy–a Harvard education. And not everyone is telegenic.
But everyone suffering from a particular disesse would benefit, equally, from having the best medical care.
And in constrast to choosing who should appear on tv,or get into Harvard being attractive, witty, well-spoken or very intelligent shouldn’t determine the level of care that you get.
Right now, to a large degree, you get the care you (or your employer) can afford. If you live to 65, Medicare is quite equitable–but what happened before you hit 65 will shorten your life.
That said, I do agree that comparative effectivenss information–with some attention to cost–is the answer to providing high quality affordable care to everyone.
Barry–
I agree that a dedicated tax is a good way to make it clear to everyone just how much we are spending on health care.
But I’m not comfortable with a two-tier system where the very wealthy pay, out of pocket, for effective care that the rest of us can’t get.
If you’re talking about minimally effective care, why would the wealthy pay for it? (Assuming the facts were made clear to the public).
If I had very young children and knew that I couldn’t get the drug that would give me another six months–but that a wealthy 70-year-old could–I would be very bitter.
Certainly I’m commfortable.
with the wealthy paying more for amenities out-of-pocket. But when it comes to effective care, I really don’t want to see it tiered.
“If I had very young children and knew that I couldn’t get the drug that would give me another six months–but that a wealthy 70-year-old could–I would be very bitter.”
Maggie,
Suppose the drug in question cost $300,000 for a course of treatment or suppose it cost $100,000 and gave the patient a chance for two extra months of life. Under the UK’s system using QALY metrics, NICE would probably recommend that the NHS refuse to pay for it. Under such circumstances, if the non-wealthy patient is angry, the anger should be directed at the system, NICE and the NHS and not at the wealthy 70 year old who could self-pay and would only be willing to do so if he/she wanted to do everything possible to prolong life regardless of side effects, quality of life or financial cost. As a society, we have to draw the line somewhere as I think you agree. Yet, we can’t stop people from spending their own money.
Drug companies, for their part, under a system like the UK’s, would quickly get the message that they need to bring new drugs to market at a cost the society can afford. If, in the end, we get less innovation, so be it. Personally, I would rather die a few months sooner and see the society remain solvent and able to fund numerous other worthwhile public and private priorities besides healthcare without driving taxation through the roof.
I get a little impatient with the notion that we can’t put a price on human life. We do it all the time implicitly in the rest of the economy. For example, when environmental regulations are debated and legislators try to come to grips with how much incremental cost to impose on industry and consumers to reduce air and water pollution, we look at such issues as how much should we as a society pay to avoid one premature cancer death — $1 million, $5 million, $10million? Or, there are perfectly valid reasons why people who work in underground coal mines are paid more than bank tellers and file clerks who work in air conditioned offices. Coal mining is much more dangerous and we need to compensate workers for that risk as well as the difficult and dirty working conditions. Or, we could probably design cars to be much safer, but they would probably more closely resemble tanks, get one mile to the gallon and cost several hundred thousand dollars. In the end, we need to allocate resources fairly, sensibly and efficiently and that means making tough and sometimes unpleasant choices. The bottom line is that we need to set limits in healthcare but we need to do it fairly and ethically. Most people probably know this intellectually, but they may think they can get everything they want by shifting the cost to someone else. That’s where transparency and dedicated taxes come in.
Maggie,
One of the reasons that you are more optimistic about what government can do is that you have not been involved in medicine since 1975 like I have been.
Maggie,
One of the reasons that you are more optimistic about what government can do is that you have not been involved in medicine since 1975 like I have been.
Barry wrote:
“As a society, we have to draw the line somewhere as I think you agree. Yet, we can’t stop people from spending their own money.”
————
Critically important to discuss this point, IMO. As I also believe that desperate consumers/patients will never be in a good mindset/info position to make this call, a caveat emptor system will suck funds from the better off who want miracles, but such a system will also reduce supply-side resources available to do the proven work for the many. Therefore, I think you can control this “spending their own money” concept at least for healthcare and at least in this country. You do it by societal-system controls on the supply-side of healthcare!
NG–
You write: ” caveat emptor system will suck funds from the better off who want miracles, but such a system will also reduce supply-side resources available to do the proven work for the many. Therefore, I think you can control this “spending their own money” concept at least for healthcare and at least in this country. You do it by societal-system controls on the supply-side of healthcare.”
I agree.
One way to do it: If the government begins negotiating the cost of drugs and devices, looking at effectiveness, and refuses to pay $60,000 a month for a drug that gives the average patient an extra 2 months (and if private insurers follow suit, which they will), drug-makers will be much less likely to develop such drugs.
So even if the very wealthy could pay for them out-of-pocket, you won’t have nearly as many high-cost low-benefit products and services available.
Legacy Flyer– This may be true. But I also find that doctors who have been involved in medicine since the mid 1960s are more optimistic than those who
came into medicine in the mid to late 70s and 80s.
re:”….a month for a drug that gives the average patient an extra 2 months (and if private insurers follow suit, which they will), drug-makers will be much less likely to develop such drugs.
Don’t know much about drug development do you maggie (I am leaving out the me to drugs, no excuse for them). Drugs often with most promise are developed based on hitting a novel target or pathway (see Gleevac). The drug companies typically DON”T KNOW ahead of time how the patient will respond in vivo compared with in vitro or animal studies ot the effect on different malignancies. That is the purpose of phase I-III studies. Jeez drug companies don’t know ahead time the response. I am know fan of big pharma but you really need to think about what you just wrote.
The price of covering everyone
Maggie Mahar takes on rationing and admits that it has to happen:
Now that we seem to be reaching agreement that we no longer want to ration care according to ability to pay, we will have to begin discussing how to ration care some other way.
She furt
I’m very late to this discussion and responded to the more recent post first, but for whatever it’s worth, I’d like to reiterate that it might help to look at the problem from the bottom up (eesential life sustaining needs and primary care) instead of from the top down (high tech, high cost, tertiary care). With scarce resources ($$, providers, infrastructure, goods and services), it is helpful to prioritize the needs first, assign it a home for responsibility and jurisdiction (local, state, federal, private commercial, private not-for-profit, public) and then craft a model which assures access and affordability for everyone.
Of course there’s rationing – there has always been rationing. The key is that in the US, those who are denied care are invisible, and so is the rationing. Wait times, for example, only include those who are actively waiting and are not denied care. If those who have self-denied, or have been refused care were included, the wait times would be enormously increased across the board.
Once again, nurses haven’t been included in Dr. Rich’s example. But I would advocate for considering adopting a community health clinic adapted model of delivering primary care.
They have track records of providing high quality, producing met or exceeded patient outcome targets, being frugal with health care dollars, and providing for high satisfaction rates by patients and physicians and nurses.
Community health clinics also use registered nurses in the most effective ways by charging them with responsibility for patient case managements (coordinating services, care and medical record test results – closing gaps and assuring that patients don’t fall through loopholes in receiving preventive care and chronic health problem management, including medication efficacy and self-care ability). As a caveat, only baccalaureate-prepared nurses have community and public health nursing as a mandated part of the basic nursing curriculum. (One more plug to mandate the BSN as the entry into practice credential and retro-fit community college associate degree nursing curricula as articulated AD to BSN programs with LPN licensure for AD graduates and RN licensure for BSNs).
Elmo–
I wrote about drug development and drug companies for Barron’s (read by investors) for many years.
Of course they don’t know in Phase I where they are headed. The problem is that once they have invested a certain amount of money and time in a drug, they hang in, during phase 3 trials when very often, they should just let go (because it becomes apparent that the benefit will be very small.)
I heard a drug analyst give an excellent presentation on this problem at a Colubmia Business School healthcare conference where I spoke a couple of years ago.
re:
“I wrote about drug development and drug companies for Barron’s (read by investors) for many years.
I am sorry maggie but because you “wrote” about drug development for Barron’s doesn’t mean you know alot about developing drugs. Do you have a pharm D. Are you an MD? Are you a BS/MS/PhD bench scientist? Are you a statistician? No, you a wonk (whatever that means). I don’t argue that drug companies can “hang in there too long”. I do know from first hand experience that drugs that were found to have limited effectiveness with one cancer are found to have much greater effectiveness with other cancers and with different combinations. The great strides that have been made with pediatric cancers have been made by using different combinations of drugs over the years (and by having the vast majority of children on study). Try looking a pediatric suvival for ALL or lymphoma in the 70’s compared to now. Following you reasoning pharma should have just chucked some of these drugs whose initial target audience (which are often much different than now used) didn’t pan out. By your reasoning we should not be using pemetrexed for maintanence therapy in stage IV lung ca (length of survival benefit a couple of months). In which case thre would be no purpose of ongoing studies using pemetrexed with additional agents. The simple fact maggie is that for every home run (gleevac), there are small step incremental studies using various cocktails of agents (see the pediatric studies) that prolong survival. Now if you want to argue “we can’t afford it as a society”…fine. Just don’t expect the ongoing incremental steps, only the occasional home run via a new target.