Tuesday, August 28, 2012
Welcome to the Fall 2012 run of the Foundations of HPM course and its blog. I hope you will find the practice of starting threads, posting reactions, etc engaging! I thought this was an interesting article in the Times by Eduardo Porter
Thoughts on how we should come to grips with the need to find a place in the health care system to say NO?
http://www.nytimes.com/2012/08/22/business/economy/rationing-health-care-more-fairly.html?_r=1&ref=policy
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4 comments:
While reading this article, I wrestled with the ethical concept of rationing health care versus that of eliminating waste. Rationing may permit finite health care resources to be better spent in other areas, but it is different from reducing the inefficiencies in our health care system that lead to waste. The author of the article cites a Harvard health economist, stating that a third of our health care dollars go to therapies that do not improve our health. The author also remarks that savings from reducing waste tend to be difficult to achieve and even with the implementation of the Affordable Care Act, which purports to reduce waste, our health care expenditures will continue to rise. Is waste reduction harder to achieve than rationing? Politically, that may not be the case, as Americans seem to have a visceral reaction when they hear that their life has a value on it. However, reconsider rationing in the sense of medical futility – that one’s life will not be prolonged because medical care is no longer effective – and the reaction may be different. While one might consent to rationing when the health care treatment won’t make a difference in one’s quality of life and their health outcome, it is antithetical to consider rationing health care treatment because of cost containment. But, perhaps I am confusing the relationship between rationing and medical futility, as the American Medical Association defines both as the following: “Rationing refers to the withholding of efficacious treatments which cannot be afforded. Futility refers to ineffective treatments.” Regardless, I think the article offers interesting insight into cost containment policies and the hard decisions that are inevitable.
It’s hard for me to embrace the idea of rationing health care, of saying “no” to someone who truly needs a service or procedure. That inevitably leads to questions such as, “When is it appropriate to say no?” and “Who gets to decide?” Nonetheless, with finite resources, we have to (and we do) limit the kind and the frequency of care that the government pays for, but I think there's room for improvement in the way we ration these things.
(As a side note, to briefly touch on semantics, I don’t really consider this a discussion of rationing health care since care is always available to those who can afford to pay for it themselves, just like everything else that’s for sale. I agree with Samantha that the thought of health care rationing elicits an emotional response that can be really counterproductive. No need to fuel any more political fearmongering.)
This article seems to focus on health insurance rationing, where Porter talks about deciding “what services are not worth the cost,” meaning the cost to the public or private insurer. I agree that better insurance rationing could be a step in the right direction if it’s done thoughtfully using evidence-based medicine. For example, if research has shown that preventive mammograms before 50 are unnecessary, these should not be routinely covered except when a doctor feels the patient under 50 is at high risk for the disease. Likewise, we should scale back on coverage for services that aren’t medically necessary or that are more cosmetic in nature, like gym memberships and lasik eye surgery.
On the other hand, the thought of cutting insurance coverage concerns me because it can already be difficult enough getting insurers to cover care that is truly necessary and life-saving. I fear that people could be deprived of critical services. Plus, it seems this tactic would have minimal impact anyway because it doesn’t address the real problem of the rising cost of health care itself. There are other things we could try first, like bolstering primary care and overhauling how we deliver care, looking for ways to make biotechnology cheaper, and public health efforts to prevent these health problems in the first place.
Another idea: Could health care rationing be self-motivated? Is there a way to shift our societal mentality so that people don’t take advantage of unnecessary services just because they can? Could our culture be more open about end-of-life discussions and accept that expensive treatments at that stage are sometimes not the way to go? Probably unrealistic, but just a thought.
It seems that everyone involved with health policy and politics agrees - on some level - that rationing is necessary. There is simply so much soup in the bowl and a lot of mouths to feed. I find it unfortunate that policy gets set, or at least influenced, by politicians who by the very nature of their need to be popular cannot be straight forward about their proposals because nobody wants to hear that their health care is rationed. Yet, as the author points out, it exists today in the form of the haves and the have-nots.
What the author seems to be pointing to is rationing based on quality of life, and points to England's "National Institute for Health and Clinical Excellence." Although the name strikes me as kind of creepy in the context of health rationing, their function seems to be very practical. There is a sense that the health of the whole is more important that the individual. I would be very interested to hear what kind of effect this has on British citizens, but I suspect that they also buy into that ideal to a degree as well and accept their recommendations. (Of course, and as noted already,in England too if this organization denies coverage for a procedure but you have the money to pay for it, you get it. So again, we are talking about rationing for the middle class and poor just as we are here in the US.)
The quality of life consideration is not one we have in the states. We focus on alive and breathing versus dead. If a patient is alive, we have succeeded. If dead, we have failed. In my opinion, this has been a harmful view of ours, both to our finances, to our medical staff, and, most importantly, to the poor people we keep "alive" who wish they were dead.
Personally, I could see myself accepting a denial of services if -- and this is a huge, monumental if -- it was explained to me compassionately. A doctor would need to sit down with me, look me in the eye, go over my medical history and prognosis, likely outcomes of further treatment, and my future quality of life. Even if I wanted to hold out hope for a miracle, I would be grateful for the truth. In contrast, if instead I got a rejection letter in the mail with the ink blot seal of some "health clerk," I would be fuming with indignation.
The question of quality of life is an incredibly important one in this discussion, as Sam and Jessica have said. The reason I am interested in doing a policy analysis paper on reimbursement for end-of-life discussions is because I think the majority of eligible/terminally ill people would opt for hospice or the like over further chemo/ICU care if they had that kind of frank and open discussion with a doctor. And then it isn't even rationing. It is informed choice.
"Rationing is inevitable in a world with finite resources. We do it in this country, too... You get care if you have the money to pay for it; if not, you probably won’t."
For me, this quote from the article sums up half of the core issue, which is that every system rations care in some way shape, or form, because (as Michael so eloquently put it) there is only so much "soup in the bowl." In a world without infinite resources, we simply cannot afford for every single person to have every single office visit, test, and procedure that they think they would like to do. So we are faced with the question: on what basis is it most fair to ration care? This is where discussions of cost-effectiveness, quality of life, and end of life care come into play. I agree with Michael, it would be great if our American society was ready to start a brutally honest discussion on how we really think these decisions should be made.
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