White Coat Underground

You can count on the Wall Street Journal for pretty good reporting and for extremist right-wing wackaloonery on the OpEd page. Today, they deliver the latter, with bonus fear-mongering at no extra charge.

The piece is entitled, “GovermentCare’s Assault on Seniors” and that pretty much sums up the content of the article. Unfortunately (at least, for the moral health of the author), there is little below the headline to justify the inflammatory headline.

Setting aside the oxymoronic tone that simultaneously lauds Medicare and condemns government involvement, the piece is one big mendacious piece of crap. The meat (or “gristle” if you will) of her argument is this:

The assault against seniors began with the stimulus package in February. Slipped into the bill was substantial funding for comparative effectiveness research, which is generally code for limiting care based on the patient’s age.

How does she justify this unjustifiable conclusion? She doesn’t. She simply asserts it. “Comparative effectiveness” is an au courant term used to describe research that looks at medical practices and tried to assess its effects. For example, there are two surgical ways to fix blood flow to the heart muscle: percutaneous coronary interventions (PCIs) such as angioplasty and stenting, and coronary artery bypass grafting (CABG or “heart bypass”). I’m not going to tell you which one is better, because the answer is complicated and still being investigated, but to choose the correct therapy for a patient we must answer a number of questions: which works best in which kind of patient; how long does each last; which has lower complication rates; which leads to longer survival; which leads to longer survival without additional need for a second intervention; which costs more, and over what time period; which makes people feel and function better. These questions and others need to be asked about many of the things we do, and comparative effectiveness research is a reasonable way to approach this.

To ignore these questions because we don’t like the answers is so frighteningly ignorant that it’s hard to believe an intelligent person could suggest it. Knowing these answers doesn’t mean it’s time to start making Soylent Green. What we do with the information is where our ethics as individual and as a society are tested. If we find that kidney dialysis in eighty year olds on average does not provide much quality or quantity of life, do we decide to stop covering it? Do we create algorithms for deciding what do offer an individual? Do we make a subjective choice in each case?

Anyone who has ever worked in an ICU knows how much futile care we provide in the U.S., but futile and improper care exists at all stages of life. Knowing what our care does and does not do is a good thing. We will be judged by what we do with this knowledge, not whether or not we collect it.

____________________________

The current wording of HR 3200 regarding comparative effectiveness can be found here. Here is a sample:

(4) TAKING INTO ACCOUNT POTENTIAL DIFFERENCES- Research shall–

`(A) be designed, as appropriate, to take into account the potential for differences in the effectiveness of health care items and services used with various subpopulations such as racial and ethnic minorities, women, different age groups (including children, adolescents, adults, and seniors), and individuals with different comorbidities; and

`(B) seek, as feasible and appropriate, to include members of such subpopulations as subjects in the research.

Comments

#1 Russell
July 30, 2009

Kidney dialysis strikes me as the very treatment that would be used as a scary example, since it is an ongoing treatment necessary to survival for those who need it. Any arbitrary age limit based on averages essentially caps lifespan for that group of patients, including those who are stable and doing quite well up to that point.
#2 qetzal
July 30, 2009

Usually I ignore typos, being markedly less than perfect myself. In this case, however, you may want to make a correction:

“Knowing these answers DOESN’T mean it’s time to start making Soylent Green.”

That aside, I enjoyed seeing this post. I’d heard some teeth-gnashing about comparative effectiveness research on the radio recently, and wondered if any of my favorite med bloggers would chime in.
#3 Orac
July 30, 2009

The link to the WSJ article didn’t work for me.

Another thing the whackaloons are going after is a provision in the bill that mandates an every-five-year discussion of end of life issues. The tone of such criticism usually runs along the lines of “Oh, no, Obama wants to kill your grandma and turn her into Soylent Green to save money!”
#4 JohnV
July 30, 2009

I tell you, we’re ignoring a great niche for biofuels.
#5 maggie_be
July 30, 2009

I’m admittedly on the finance side of healthcare (I’m the reimbursement manager for teaching hospital) and I appreciate having a doctor’s POV (because, frankly, except for the CFO, finance staff basically never get to converse with the physicians …) I have a question. From a financial point of view it seems like to lower costs we will, in fact, have to ration healthcare. We already ration, we just informally (or, perhaps, clandestinely) ration on ability to pay. If we provide basic coverage to everyone (and I think you can’t deny that, morally, we should) then we will undoubtedly release pent-up demand and it seems to me that will increase costs, not lower them. Plus, it will push informal rationing to some other method (perhaps doctors or hospitals will not take the new basic insurance due to low payment, etc.) I can see why some people feel implementing evidence-based stds won’t lower costs and I can see why other people see it as a slippery slope to rationing. So, what from a physician POV do you think? Will evidence-based stds alone lower costs or is some rationing necessary given a non-finite supply of dollars?
#6 PalMD
July 30, 2009

I’m not convinced that evidence-based standards will lower costs prima facie. Costs can be affected in a number of ways:

1) Evidence-based standards can cut down on unnecessary testing driven by testing profit centers.

2) Evidence-based prevention can cut down on costs by, for example, preventing amputation in diabetics. This can be done simply by doing regular foot exams, and inexpensive intervention.

3) Screening can actually increase costs, by catching more disease which may be treatable, but may or may not improve outcome.

I would suppose that any public plan would encourage hospital participation in some way, whether via incentives simple mandate. I suppose DiSH dollars would factor in somehow, but as most HCPs know, Medicaid pays shit, Medicare pays reasonably well (usually, sort of).
#7 Terry
July 30, 2009

Why is this so important today? Why didn’t it mean anything 2000 years ago when people became ill and died, were injured and died or became old and died?
This is just a rehash of the Culture Wars, wherein the rich allocate resources to prolong life, and everyone else catches as catch can the drippings of life prolongation.
Since, for all practical purposes, we only remember two generations back as it is, why do we care about 100 generations in the future? What exactly is the point of extending life 1 year, let alone 5 or 10 years?
If people will just think, and shed the Xian belief in future life and crazy moral sanctity of life models, we wouldn’t be in this conversation.
#8 JohnV
July 30, 2009

What’s the point? Not being dead maybe?
#9 PalMD
July 30, 2009

I have to admit that if there was a coherent point to be made by Terry, I have no idea what it is.
#10 maggie_be
July 30, 2009

I suppose DiSH dollars would factor in somehow, but as most HCPs know, Medicaid pays shit, Medicare pays reasonably well (usually, sort of).

From a hospital POV, Medicare Advantage (the HMOs) pays very well, Medicare pays so-so and Medicaid is hopeless (even if you can actually get them to pay anything at all and not just deny the entire claim on first billing.) With a public plan they could force providers to accept the reimbursement but I’m not sure that will actually lower cost if you’re covering more individuals. And what happens to the way we make our bottom line now – by cost shifting to the commercial insurers? You can say hospitals maybe shouldn’t have much of a bottom line, that reimbursement should be lowered and that would save $, but how do we fund new and more advanced equipment in that case? From the current news reports I’m thinking a public plan is now a dead duck and I’m still not understanding how anyone is really addressing cost in the whole equation because no politician in his or her right mind will utter the word “rationing.” In other words I appear to be more throughly confused than most people I know and I work in the industry.
#11 BaldApe
July 30, 2009

I certainly agree that the most cost effective treatments are to be preferred, but I am concerned, along the lines of the complications you pointed out, that insurance functionaries in their cubicles will make such decisions in lieu of my physician making the difficult judgment calls you allude to.

IOW, if my doctor says I really need treatment X, shouldn’t that count for something?
#12 PalMD
July 30, 2009

In other words I appear to be more throughly confused than most people I know and I work in the industry.

You are confused BECAUSE you work in the industry. The more you know, the more simplistic and nonsensical some of this seems.
#13 PalMD
July 30, 2009

I don’t think I’ve every emphasized “cost-effective”. Cost is only one measure of many.
#14 Catharine
July 30, 2009

I certainly agree that the most cost effective treatments are to be preferred, but I am concerned, along the lines of the complications you pointed out, that insurance functionaries in their cubicles will make such decisions in lieu of my physician making the difficult judgment calls you allude to.

Ha! Insurance companies? Doctors?? Usually it’s the families (“customers”) making the judgment calls (which they are usually ill equipped to make)!
#15 qetzal
July 30, 2009

Regarding cost, I’m still trying to understand why we in the US supposedly pay so much more for our healthcare than essentially all other ‘wealthy’ countries. The basic claim is that we spend 16% of GDP on healthcare, with all other Western nations paying no more than 11%.

This report from the McKinsey Global Instutitue addresses the topic. It has lots of data, breaks down US healthcare spending in great detail, and compares it to other countries on a percent of GDP basis. I recommend it to anyone who’s interested in such comparisons. But in the end, all it really says is that health costs in the US are substantially higher (as a fraction of GDP) than for any reasonable comparator nation. Even assuming their numbers are correct (which I don’t necessarily), it’s not clear to me why we spend more.

Of course, I’ve heard lots of explanations offered. ‘We pay way more for drugs.’ True, but drugs are only a small fraction of total health care costs. Even if we cut our drug costs in half, the total effect would be quite small.

‘We pay for most of the world’s medical R&D.’ Also true, but again the amount in question is a very small fraction of total health costs.

If anyone knows of other good rational analyses of these issues that they can point me to, I’d really appreciate it.
#16 D. C. Sessions
July 30, 2009

qetzal @15:

Factor in that the insurance industry has an “medical loss ratio” of less than 80% — in other words, 20% of that 16% stays with the insurance companies. Drop that to 3% or so (Medicare admin overhead) and you get the USA down to a bit over 13% — which is closer, if not great.
#17 Whitecoat Tales
July 30, 2009

Ha! Insurance companies? Doctors?? Usually it’s the families (“customers”) making the judgment calls (which they are usually ill equipped to make)!

I sense a lot of rage.

You (the impersonal you, not you catharine… the english language lacks a good impersonal tense) can’t have it both ways. The public complains about paternalism if doctors make the difficult calls. Yet if doctors don’t make the judgement calls, this gets thrown in your face.

This is really a false dichotomy. No decent doctor leaves these difficult decisions entirely to the patient, yet no doctor tells their patient “this is what we’re doing.”

Good doctors compassionately talk their patients through these difficult situations, and steer their patients towards the judgements that fit what the patient tells the doctor is important to them. The patient always always always can refuse something they consider inappropriate, yet the doctor isn’t just a mechanic in a car shop suggesting you get your brakes fixed.

For the record, I have NEVER, EVER considered a patient a “customer,” and I find the usage of that word insulting.
#18 Charlotte
July 30, 2009

The only types of rationing I’m familiar with in the UK are:
1)having to wait longer for non-urgent surgeries etc (unless you have the money to pay for private treatment)
2)generic drugs – the branded ones are pretty rare here IME
3)some very expensive treatments, particularly for cancer, aren’t available under our system. They’re usually the ones which give some patients a few extra months at the cost of horrible side effects – really effective treatments tend to get approved pretty quickly, especially if they get a little public pressure behind them.

The only age-related rationing I’ve ever heard of is of transplant organs. That wouldn’t be an issue if more people were donors, as it is they have an algorithm to decide who’d get most use out of them. They’re also less likely to do elective surgery on over-60s, on a risk-benefit basis. But mostly, they keep you alive here until you – or your family – tell them to stop.
#19 Catharine
July 31, 2009

#17 I’m afraid you have deeply misunderstood me. Let’s have this conversation again after you’ve had some experience in critical care, and after you’ve been under direct pressure from the hospital to raise press-gainey scores, and after “your” patients’ families order from the DNR menu (and directly contradict the patient’s advance directive) or choose from a variety of futile treatments, which you will (I promise you) offer.

However, you did get the rage part right. Mazel Tov. (You have a keen grasp of the obvious.)

Shouldn’t everybody feel rage in the face of social injustice?
#20 Whitecoat Tales
July 31, 2009

I do have experience in critical care, we’ve had those conversations about press-gainey scores, and I’ve called the ethics comittee myself for patients who have, in a variety of ways, wanted to contradict a patients DNR. I do go to medical school, and I spend my time in a hospital, not in the land of milk, honey and fairies and people who live forever.

So if I’ve misunderstood you, please correct me, and explain what exactly doctors are doing wrong, and why you rage against physicians so much.

So far, it doesn’t sound like you’re blaming the system or the bureucrats, it sounds like you’re blaming doctors. Yet I don’t see what you’re saying doctors are somehow systematically doing wrong that arouses your rage at the “social injustice” of it all.
#21 melospiza
July 31, 2009

The primary virtue of the Oregon Health Plan (currently severely underfunded and using a lottery for who gets in) is open rationing by diagnosis. If your diagnosis is under the cutoff line on the list, the OHP doesn’t pay. (There was a kerfluffle a few years ago about a young woman who needed a multiple organ transplant. Not on the approved list–not cost-effective, poor chance of good outcome, etc. She died.)

We have to ration somehow. We can’t afford everything for everybody. This seems to be the best way. Not paying for ER visits for a cold, for instance. Or acupuncture. Instead of rationing by ability to pay, or by employment, or by preexisting condition.
#22 PalMD
July 31, 2009

Without stating an opinion for or against, rationing is not ethical if it is not explicit.
#23 Donna B.
July 31, 2009

WCT — I’ve got a little beef with you not considering your patients as also customers. But then, I also have a very old-fashioned idea of customer service.

I do want to be treated as a customer when I see a doctor or go to the hospital. The alternative is to be seen as a commodity to be sent down the assembly line. Or as something to be “stored” in an out of the way place until it demands attention. Or considered a “form” that must be filled out then filed away.

I’m not really talking about doctors, but the way the businesses they operate within are run… their offices and hospitals and the other medical personnel that staff them.
#24 Whitecoat Tales
July 31, 2009

Perhaps if you can consider a higher standard of customer service, we can agree. I’m too used to customer service being an unending list of call center jibber jabber and people trying to make it tough to get anywhere.

I’m not a fan of institutional cultures that treat patients like a commidity either mind you, I just don’t think those are the only alternatives, but I know better then to tell them how to do their jobs.

I just treat my patients like people.
#25 PalMD
July 31, 2009

Customers enter into an economic relationship, patients into a fiduciary relationship with many more ethical contraints
#26 Donna B.
August 1, 2009

WCT – Call centers are NOT customer service centers, they are customer obfuscation centers. I certainly do consider customer service in the more old-fashioned way and definitely a higher standard.

While you might know better than to tell them how to do their jobs… um, I never learned that.

PalMD – I certainly agree that a doctor/patient relationship is more fiduciary that strictly economic, but there are days I’d settle for being treated economically valuable as a patient!
#27 Catharine
August 1, 2009

Oy. One more try.

First: WCT: At no point in #14 or #19 do I express any “doctor rage,” which you have mistakenly diagnosed. On the contrary, I understand (probably more than you) the kind of impossible corners physicians are backed into regarding futile care, the threat of lawsuits, and real life and death ethical dilemmas. It would be nice if the world worked the way your sentiment describes (#17 “Good doctors…) but it doesn’t. I have seen cases day after day, month after month, year after year, decade after…well, you get the idea… both as a person in the trenches and as a member of the Hospital Ethics Committee and the problems facing patients/families are usually very complex and rarely have one “good” solution.

Do I blame doctors for this? Hell no! The problem I see is the McDonaldization of medicine, by that I mean the consumer model of medicine which wants to replace best medical/nursing practice with best profit. This is how patients turn into “customers,” and we all know the customer is always right. Right? Wrong. My sarcasm in #14 was lost on you (quotation marks were a hint). Let me be clear: I find the McDonaldization of health care repulsive. Are you with me so far, WCT?

Ya know what else I find repulsive? Out. Of. Control. Capitalism. I have a problem with the fact that MILLIONS of people in this country (including the not-so-legal residents) do not have access to basic health care. I have a problem with the fact that many more people who have insurance (for which they pay dearly) STILL cannot afford to actually go to the doctor/dentist because deductibles/out of pocket costs are too high. Nobody seems to feel that public schools, public transportation, infrastructure, or even public parks are uncalled for or threatening. Why is the idea of public health so frightening? Guess what? When people get sick enough, they end up in the hospital anyway – money or no money. And we do pay. Making health care public is cost effective in the long run.

Do I blame doctors for this? Of course not. Perhaps you have this impression because, in a different thread, I asked doctors, “How much money is enough?” There was a lot of lamenting the huge debt one can incur for the sake of a medical education, although nobody offered an unambiguous answer to the question. Big numbers, for sure. I do believe that medical education should be subsidized. But let’s be honest and compare the huge number that is your debt to the number that is your earning potential – which is in some cases “very comfortable” and in some cases ginormous. To ask “how much is enough?” is not to make an accusation. It’s a fair question. I am perfectly happy for doctors to make piles of money. I am not so happy when an insured teacher can’t afford to see a doctor when she needs care. It would be interesting to compare the number of doctors in private practice that see patients pro bono with the number of doctors who require payment be made *before* you are even seen. The latter is so tacky.

Another thing that got some goats on that other thread is that I compared teachers’ student loans :: earnings to physicians’ student loans :: earnings. The point was not about which profession has more education or value, the point was that it is far easier for a doctor to pay off a huge debt than it is for a teacher to pay off a small one. Again, no bad on doctors here. But teachers should *definitely* have a free education.

So, WCT, sorry to disappoint but no “doctor rage” here. I do hope you have understood me this time because I have no intention of boring myself or you any longer. And I do resent the sometimes subtle, sometimes not so subtle judgment that I am mad — in both senses of the word.

Pal: A better translation for tzedakah (at least the one I grew up on) is JUSTICE.
#28 Donna B.
August 1, 2009

Catharine – if I thought any of the proposed new health care laws would make access any easier for everyone, I’d probably be more for it.

But, it looks like to me, that access is going to more difficult for everyone (including the currently uninsured) just to make sure the lack is equal.
#29 PalMD
August 1, 2009

But, it looks like to me, that access is going to more difficult for everyone (including the currently uninsured) just to make sure the lack is equal.

And on what do you base that assertion? (and a vague “gov’t always fucks things up” is not an answer)
#30 Donna B.
August 1, 2009

True, it’s an assertion (and a gut feeling) that things are going to get much more difficult for everyone.

First, a little background so that maybe you can understand my POV a little better:

I’ve been the “point man” in choosing health benefits coverage for several small businesses. I have a disabled son who has had no coverage, Medicaid (in three different states), and now Medicare with Medicaid covering his prescription benefits. My brother is also disabled and has Medicaid only. I was an uninsured single mother with 3 children (one disabled) for 7 years. I also at one time had the best HMO coverage possible and now, years later have something similar through Tricare.

1. After my son left home, he had no insurance and often no income. For years, he got all the medical care he would let anyone provide him with at no cost except to his credit report. You, I, and every other taxpayer contributed. Now that he’s more settled with a steady income from SSDI with Medicare coverage, he’s faced with copays and travel expenses to approved providers that strain his budget thin. His PCP (at 1/3 the copay of a specialist) will not prescribe psychiatric drugs, so he has to pay extra to get prescriptions that aren’t covered by Medicare Part D. His doctor and prescription copays cost him ~$200/mo. I subsidize him as often as I can. Before he had insurance, his bills were basically written off. The taxpayer is still paying about the same, because he has to see more providers more often to get what he was getting for “free” before. Bottom-line, it costs him more now that he has insurance than it did before.

2. My brother is 62, old enough to get Social Security, but not old enough for Medicare. He opted to claim disability, which cut his Social Security almost by half, but allowed him to get Medicaid benefits. It also allowed him to get low-income housing. Before doing this, he was in the same boat as my son — could get “free” medical care with the only penalty being a bad credit rating. Unlike my son, he’s faced with a severely limited choice of providers who accept Medicaid, thus “access” — getting an appointment — is limited.

What has changed for both my son and my brother is that now that they are “in the system” both pay more and have a larger problem with access to care than they did when they were uninsured and simply abused the ER by using it for primary care. I honestly don’t know which method costs the taxpayers more. I suspect the costs are actually quite similar, but don’t have numbers to back that up.

I am NOT suggesting that the previous actions were right or ethical or moral. I’m simply pointing out that they had easier access and paid less (with little or no punitive response) before they had insurance.

On the other side of the picture, since I re-married I’ve had fantastic insurance. My husband is retired military, so we have Tricare. My husband has Medicare and Tricare as secondary, so it’s rare that he pays anything at all for medical care. I’m not 65 yet, so we pay the premium for me to have Tricare Prime. There is an MTF near us, so theoretically all my PCP visits should cost me $0. Since the MTF is understaffed and I’m a retiree dependent, I usually am referred off-base. I don’t mind… I’m still very happy with our coverage and our co-pays.

While I do not know (does anybody??) exactly what the healthcare reform will do with Tricare, I suspect that our benefits will “probably” be reduced in some way. I realize we’ve got it really good right now. Because of the fear of reduced benefits, my husband is probably going to apply for a VA pension and the Atomic Vets compensation. Most of his current health problems are likely due to Agent Orange exposure in Vietnam and exposure to above ground nuclear testing in the early 60s.

Either way, taxpayers will be paying for our health care and we are grateful, however there’s a bit of a feeling that it’s been earned in my husband’s case. In fact, they’ll be paying more because my husband would not even consider applying for his VA benefits before all the talk about healthcare reform and the fact that we are essentially left in the dark about how it might affect us.

During the 7 years after my first husband died and I was a single mother with 3 children… I was lucky. I had a job at a very small company which did not offer health insurance, but paid a decent wage. I paid out of pocket for checkups and vaccinations and a few trips to the ER (more often than not after a bicycle wreck.)

If I thought that the country could afford to provide something similar to Tricare Prime for everyone, I’d be all for it, but I cannot see how that is possible. While my treatment at the MTF is “free” to me, it also provides a patient load large enough to justify keeping it open for the use of active duty military. At least that’s what I’ve been told. Even when an off-base provider orders tests, if they are available at the MTF, I get them there. It’s prepaid in a way because those people and that equipment is already paid for whether I use it or not. I get all my lab work and x-rays there regardless who orders it. (This is not required of me, but it should be. I honestly try to not cost the taxpayers more than necessary.)

Gov’t doesn’t always fuck things up, but they are getting better and better at it!
#31 Donna B.
August 1, 2009

WCT — this is part of what I am talking about when I say that patients should be treated as customers:

http://www.nytimes.com/2009/07/30/health/30chen.html?ref=health

A patient should feel just as comfortable asking about a medical procedure as he does asking about a menu item in a restaurant… and doctors should be as informed about any procedure they are suggesting as a waiter is about the daily special.
#32 DLC
August 5, 2009

Of course it isn’t really a simple problem.
but, in 1999 I had a cystoscopy. I won’t go into the ins and outs (pun intended) of the procedure, I will just mention that when the Explanation of Benefits arrived at my door, I found that my insurance company was billed $32.00 a bag for IV Saline. Thirty-Two United States (1999) Dollars per bag of freakin salt water. (okay, it’s sterile salt water… but still) Crikey. 32 USD. WTF ? This is idiotic. sterile saline must cost what, 10 bucks per liter to make ?
#33 daedalus2u
August 5, 2009

DLC, it isn’t just sterile salt water, it is sterile salt water that has been produced under “good manufacturing practices”, stored under GMP, tested for sterility, for pyrogens, etc. Each of the ingredients was tested and the final mix was also tested. I am surprised it was only $32.
#34 PalMD
August 5, 2009

Also it is “non-pyogenic”, meaning it has been tested for endotoxin, which isn’t destroyed by normal sterilization practices. Sterile saline alone cannot be injected.
#35 MikeB
August 7, 2009

I’m not sure where the whole ‘rationing’ meme is coming from, never mind the idea of ‘euthenasia’. Charlotte (post #18) puts pretty well the situation here in the UK – we have no real problem with ‘rationing’ over and above the usual factors of bed space, etc. Drugs costs are controlled in certain cases (starting with NICE), but these are actually fairly untypical, and have been highlighted by drug company lobbying.
I would disagree slightly with her point that branded drugs are rare in the NHS. They are not, although the NHS is doing its best to get GP’s (in particular)to look at generics rather than branded where possible.

I get the impression that many people in the US have been frightened by tales of ‘socialised’ healthcare, and by myths over what will happen if you are are old and ill. The reality, from the UK perspective, is continuing care, paid for by the state. From a European or Canadian perspective, these fears are simply irrational, and bear no relation to reality.