White Coat Underground

An easy way to kill a debate on health care policy is to use the “R” word. We saw this early in the HCR debate with overheated talk of “death panels” and other nonsense. But we ignore the real issue of rationing at our own peril. Those of us who favor real HCR must embrace rationing, coopt it, show our opponents how it is inevitable.

Nowhere is the the Right more hypocritical than the issue of health care rationing (OK, maybe with sex stuff, but…). Everyone who studies American health care knows that we already ration; we just do it irrationally. Current rationing allocates resources to the wealthy and those with good jobs, and when we do care for the uninsured, unevenly spreads that cost to some hospitals and taxpayers. Medical services are reimbursed in an unstable fashion, with some services reimbursed well one year, and poorly the next, making planning nearly impossible for doctors, hospitals, and patients. For example, there are currently large cuts planned for some cardiology services, cuts which I don’t disagree with in theory but cardiologists cannot provide good service to their patients if one year they are encouraged to go out and buy lots of fancy equipment and the next year are told they can’t use it.

Hospitals struggle from year to year as economic downturns change the payor mix driving down income. There is no stability in our current system. It is not robust, for providers or for patients.

But explicit rationing—and we might as well use the word, because our opponents sure will—can help stabilize costs and improve the our health care system. Any doctor or nurse knows that ICUs are filled with people who will never walk away. Pandemic emergency plans recognize this, and if our current flu pandemic gets any worse, we will see limited resources allocated to kids rather than the hopelessly, terminally ill. Why wait for a pandemic? Comparative effectiveness research can help guide our policies. Do bed-bound octogenarians benefit clinically from hip replacement surgery? I suspect not, but if studies bear out my suspicion, shouldn’t we stop torturing them for cash and allocate scarce resources where they are needed?

Conservatives hate the idea of rationing—hell, everyone does, but conservatives especially because it cuts into our “freedom”. But “freedom” means nothing if you don’t have insurance. You’re only free to rot. I struggle every day to get care for diabetics who can’t afford necessary testing materials. This is basic care, not some high-end, experimental treatment. How can we, as a nation, continue to ignore basic prevention and proven treatments in favor of the libertarian fantasy that is our current system?

The Times just published a piece on paying for alternative medicine. It acknowledges that these treatments are unproven, but then goes on to tell consumers how to get them. There are practices about which reasonable people can disagree—at what age to start mammograms, at what age to stop colon cancer screening, etc—but to take our scarce resources and throw them away at acupuncture and herbs is narishkeit.

The first step in rationing rationally is to make the system transparent. Currently, if you are denied care, there is often no explicit reason given (except perhaps a pre-existing condition or your own poverty). To be ethical, rationing must be explicit, transparent, and understandable. We could start by rationing clearly unproven therapies, such as acupuncture and chiropractic. If people want them, then they can pay out of pocket. We can then move on to comparative effectiveness research on expensive mainstream procedures. ICU care for the dying might be a place to start. Even inexpensive procedures add of fast and may provide low-hanging fruit.

No one likes to talk about rationing, but if we are going to have a sustainable health care system in this country, we have to make difficult decisions. Let’s do it deliberately and in the open.

Comments

  1. #1 Dave
    November 14, 2009

    Pal, you never cease to impress me with your courage and truthiness. Please keep up the good work.

  2. #2 Nico
    November 14, 2009

    I can’t fathom that if there’s truly NO money to spare for a more universal plan, why the altmed is even being contemplated for inclusion in a basic level of service.

    Currently in Canada, if you want chiro, and the like you’re paying out of pocket or via private insurance you can choose to buy if you want that coverage.

    We have private insurers, they’re just constrained to what is for the most part the “extras”.

    I fully agree though, that there already is rationing in the US, but wonder if some of the fear of a universal system is that if you’re rich, suddenly, you might not simply be able to buy your way to the head of the line. Oddly, I’ve never experienced any sort of rationing in Canada like they fear happens, but they won’t/don’t believe it.

  3. #3 Ejay
    November 14, 2009

    If you think the teabaggers are hysterical now, wait until they learn that chiropractic and homeopathic treatments may not be covered.

    Remember some years ago when the FDA tried to get supplements controlled for purity and safety? Radio and newspaper ads ran, advising people to arm themselves to protect their eye of newt and toe of frog. Jack-booted government thugs were going to smash into your house and if you had ginko bilboa in your medicine cabinet they would send you to prison.

    Let the fun begin.

  4. #4 DLC
    November 15, 2009

    Truthiness? is that Colbert up there ?

    Of course, it’s not going to be “Medicare for Everyone” as some media personalities have called for. I’m really not sure it’s going to be any reform at all. Some of the things I here about HCR sound rather ominous, and I’m not speaking of the so-called “Death Panels”, or even “socialized medicine.”
    I’m thinking of the mandate that everyone buy insurance.
    Is that piece of piracy-in-waiting even still being considered? I suppose I should check, but I’m tired and having pain. I’ll look later.

  5. #5 Bill
    November 15, 2009

    It can’t be “Medicare for everyone” because Medicare itself has seen costs boom out of control.

    Unlimited fee for service medicine is not going to be the future of health care.

  6. #6 Philip Tan-Gatue
    November 15, 2009

    “We could start by rationing clearly unproven therapies, such as acupuncture and chiropractic”

    I object to this statement wherein acupuncture is termed “clearly unproven”. I suggest a quick pubmed search to the numerous single-blinded (acupuncture, being a procedure and not a pill, is quite difficult to double blind. Is surgery double blinded?), sham-controlled studies yielding statistically significant differences between “real” vs “sham” acupuncture or placebo. There are many so long as you choose to look at them.

  7. #7 WcT
    November 15, 2009

    @Philip Tan-Gatue

    You can object all you want. You’re wrong.

    Do a quick pubmed search and you’ll find all of the largest trials show no difference between sham and “real” acupuncture. It’s happened often enough that now acupuncture advocates are saying “well that proves that sham acupuncture works too!”

    The balance of evidence says that acupuncture is just a very expensive placebo.

  8. #8 D. C. Sessions
    November 15, 2009

    I suggest a quick pubmed search to the numerous single-blinded [...], sham-controlled studies yielding statistically significant differences between “real” vs “sham” acupuncture or placebo.

    Yeah — the sham acupuncture “works” better!

  9. #9 CG
    November 15, 2009

    Studies which compare acupuncture to conventional treatment, for the treatment of pain, for example, show that acupuncture is the superior intervention, i.e. there are significant differences in reported pain levels in the acupuncture groups. The fact that some of these studies also show that there is no difference between the acupuncture and the placebo group (sham acupuncture group) only indicates that there is no good way of blinding a study participant to whether they are receiving acupuncture or not, and that sham acupuncture is not an effective control method.

    Given acupuncture is an effective and low-cost intervention, especially when also considering the additional costs of adverse reactions to painkillers, it warrants a place in the management of pain.

    As for the comment that “The Times just published a piece on paying for alternative medicine. It acknowledges that these treatments are unproven, but then goes on to tell consumers how to get them.” – you’ve been duped. This editor’s note that has preceded ALL Associated Press online ‘newspaper’ articles on alternative medicine whether the reporter is writing a positive or negative news story on alternative medicine – so much for objective and independent reporting… Don’t believe everything you read in the media.

  10. #10 David
    November 15, 2009

    The essence of medicine is caring for an individual patient. The essence of social science is thinking at the broad level of societal outcomes. They are in conflict, and I do not believe that conflict can be resolved.

    The preferred measure among “rationers” is the QALY. This is established by interviews with usually healthy people to see how they would rank various outcomes. Inevitably, care for relatively minor problems in basically healthy young people get ranked far above care for people with serious disabilities. But people with disabilities wouldn’t see it that way. The measures used by social scientists to enable rationing are cold, calculated, artificial and contrary to the ethos of medical practice.

  11. #11 Ramel
    November 15, 2009

    The fact that some of these studies also show that there is no difference between the acupuncture and the placebo group (sham acupuncture group) only indicates that there is no good way of blinding a study participant to whether they are receiving acupuncture or not, and that sham acupuncture is not an effective control method.

    Anyone else just facepalm?

  12. #12 MonkeyPox
    November 15, 2009

    “just as good as placebo” = “just as bad as placebo”

  13. #13 Ryan
    November 15, 2009

    Just wanted to give a heads up for the best essay on rationing I’ve seen: Peter Singer’s July piece in the NYT Sunday Magazine.

  14. #14 Mike
    November 16, 2009

    Health care is not currently rationed irrationally, as it, like just about all scarce resources, is allocated upon ability and willingness to pay. It is no more irrationally allocated than copper, lumber or housing.

    Central planning as a method “rationally” allocating goods is a repeatedly proven failure.

  15. #15 Sam N
    November 16, 2009

    @11, yes. I had some disbelief that CG is really that stupid, but I reread it, and yep, that stupid.

  16. #16 PalMD
    November 16, 2009

    @Mike

    Health care is not a commodity like any other.

  17. #17 Ramel
    November 16, 2009

    Central planning as a method “rationally” allocating goods is a repeatedly proven failure.

    You mean like the total failure of centraly provided services like roads, law enforcement, schools, the military or fire and rescue?

  18. #18 Mike
    November 16, 2009

    Ramel, here in the US, none of the items you described are centrally allocated by one all knowing and all powerful government. Rather they are a mixture of private and public allocations through a variety methods. Even the military is not centrally allocated. There is the US military, the state level national guard and the militia which is every able bodied citizen in the US.

    PalMD, some parts are commodities like pork bellies or housing or other thing necessary for human survival. The one aspect that differs is communicable disease prevention.

  19. #19 joe
    November 16, 2009

    let me tell the good doctor why he should fear obamacare – doctors fees will be cut by 30%. read it and weep into your tea.

  20. #20 Ramel
    November 16, 2009

    Thank you mike for the second facepalm of the thread.

  21. #21 Philip Tan-Gatue, MD
    November 17, 2009

    @WCT and D.C. Sessions
    I also forgot to mention that the mistake among many “trials” is that it treats acupuncture like a drug. Acupuncture is NOT a drug. It is practitioner dependent. There are good surgeons and bad surgeons. There are skilled acupuncturists and wanna-bes who only know how to poke needles but not how to manipulate them. Do we do double blind or sham controlled studies on surgical patients?

    I can see it now. We’ll just cut this guy open and pretend to do something. There’s our sham control.

    We’ve conducted our own studies on acupuncture here in our university (still unpublished though) and we found that trusting the patient to stimulate ear acupuncture points by themselves usually leads to failure, but if we did the ear point stimulation ourselves it works better.

    A quick search on my part revealed two already
    http://journals.lww.com/clinicalpain/Abstract/2009/05000/Electrical_Acustimulation_of_the_Wrist_for_Chronic.10.aspx

    http://www.ajog.org/article/S0002-9378(09)00424-4/fulltext

    Since I’ve started on the topic of research, might I suggest the studies conducted by Berman, Stux et al? All M.D. like myself if I may add.

    What I find hypocritical about some studies I’ve read is the sheer ludicr

  22. #22 Philip Tan-Gatue, MD
    November 17, 2009

    oops I forgot to erase that last fragment.

    People are free to believe what they want, as long as they can cite credible evidence to support their point. I believe that there is sufficient evidence to show acupuncture works. I acknowledge that there are those who believe the evidence shows otherwise.

    I am not objecting to your belief in your point. I am objecting to your comment that it is “clearly” unproven.

  23. #23 Philip Tan-Gatue, MD
    November 17, 2009

    @cg
    Since the WHO adapted their standards for acupuncture research, usually researchers try to do three groups: patients where true acupoints usually indicated for the problem being treated are used; patients where acupoints not usually indicated for the problem being treated are used and/or fake stimulation for “true” points are used and lastly, control groups where no acupuncture is done. I believe this is the most rational way to go about it.

    I also realize that acupuncture is like ultrasound – it is operator dependent. Unlike an x-ray, which you can show to any physician and have different interpretation depending on experience and skill, ultrasound is dependent on the skill of the sonologist.

    Acupuncture is the same way. I’ve experienced being treated both by an expert and by a pretender. The pretender actually made my shoulder pain WORSE.

  24. #24 Calli Arcale
    November 17, 2009

    Do we do double blind or sham controlled studies on surgical patients?

    Actually, yes, it is done. Usually, it’s a double-blind comparison against some other treatment option (usually also surgical), but in rare cases, there is actually a sham surgery performed. It’s rare, because of course it’s unethical to open up a person (risking infection and certainly facing significant injury) for no gain whatsoever, but for some minor surgeries, sham treatments have been used in some studies.

    Obviously the skill of the surgeon is a factor. So is normal variation; Person X has subtly different anatomy than Person Y, which means you may well run into things you didn’t expect when you open them up which will affect the outcome. But that doesn’t make it impossible to study. It only means you need to recruit enough surgeons and patients to overwhelm these effects.

    BTW, I disagree that x-ray is not operator dependent, and I know a few radiologists who will beg to differ. ;-) As with ultrasound and other imaging technologies, if the technician doesn’t know what they’re doing, the results may be blurry, poorly positioned, over- or under-exposed (though modern technology mitigates that), or obscured by other anatomy. The operator needs to know what they’re doing; they’re not just button pushers.

  25. #25 Steve
    November 17, 2009

    I agree with you. We should ration healthcare in the most productive way. This means that the most productive members of society should get the best health care and the least productive should get the least. Let’s start by providing no health care to anyone without a job. Clearly that person is an unproductive member of society, and therefore, why spend money to keep them alive. From there, let’s cut care based on income or career rospects.

  26. #26 Calli Arcale
    November 17, 2009

    I don’t think PalMD was suggesting anything of the sort, Steve. We do need to ration health care, simply because the demand outstrips the supply. Currently in the US, it is largely rationed the way you suggest — those without jobs (or the wrong kind of jobs) are far less likely to have insurance and be able to obtain health care. It would be far more compassionate — and, ironically, probably cheaper — if we rationed based on need instead.

    Is it fair that I have access to care anytime I want (I can afford to see the doctor for the sniffles, even though odds are it won’t make a lick of difference if I do), while my unemployed mother can’t afford to see the doctor for the regular checkups needed to make sure her synthroid levels are correct? She even toughed out a broken foot. (Didn’t tell anyone in the family about it until later, or we would’ve paid for her to get it set properly.)

    No, it’s not fair. It’s life in the US today, but it’s not fair. If we must ration, we should ration based on where the care is most likely to help, not based on who is best able to pay. Not only is this more compassionate, but it’s actually going to be much more efficient as well, because we won’t end up paying for excruciatingly expensive end-of-life care and emergency care for people who really needed care a long time ago.

  27. #27 Philip Tan-Gatue, MD
    November 17, 2009

    @ Calli thank you for graciously pointing out where I was wrong in a tactful way. And you are right in that I was a bit inaccurate to say that an x-ray is not operator dependent. Let me clarify that. being a radiologic technician requires a particular level of skill, yes. But granted that the technician (or in China, the radiologist himself does the work), does the job right, showing the film to different radiologists with varying level of skill and experience may yield different results – given the same film. Whereas in sonography, a lot depends on the manual skill and dexterity and astuteness of the sonographer. If he gets it wrong there, it’s all wrong. Same with acupuncture. It requires skill – it isn’t just poking the needles and hooking them up to the machine.

    About the surgical part – while I understand that sometimes surgeries are performed experimentally and results compared to other surgeries, I believe that that is different than with acupuncture. Acupuncture wise, that would be comparing one protocol with another protocol, but not comparing one protocol with a “fake” protocol. That’s what I meant by comparing a real surgical technique with just cutting a patient open and pretending to do something.

    And when I was talking about good surgeons vs bad surgeons, I was assuming that everything else being equal. Isn’t that what studies try to assume – and why we try to get as homogenous a patient population as possible?

    But I digress, this blog entry was about health care rationing, and I must put in my two cents here.

    I find it interesting that in the US, the shift in healthcare seems to be in the direction that China is heading away from, as China healthcare becomes more and more out-of-pocket.

  28. #28 Calli Arcale
    November 18, 2009

    You’re welcome, Philip. ;-) With x-ray techs, I’m just remembering a couple of bad x-ray experiences. The techs were *nice* and all, and it wasn’t traumatic or anything. The films were just worthless. It is a great deal like photography in that the skills needed don’t involve so much manual dexterity and are easy to overlook, yet have an equally subjective factor to them.

    I find it interesting that in the US, the shift in healthcare seems to be in the direction that China is heading away from, as China healthcare becomes more and more out-of-pocket.

    The world is a strange place, is it not? I wonder if a trend towards out-of-pocket health care (as opposed to socialized medicine) is associated with rising prosperity. Certainly China is facing that, in spades.

  29. #29 Philip Tan-Gatue, MD
    November 18, 2009

    @ Calli

    Oh my, I know exactly what you mean about x-ray technicians and bad films. We had an experience in our hospital with a cancer patient with bone metastases. As the tech turned the patient’s legs to shoot lateral views of the femur, he literally snapped her bones like a twig…

    About socialized medicine, I believe that a healthy balance is needed. If everything is commercialized – bad. If everything subsidized -also bad. Rationing, yes. And “alternative” treatments to be out of pocket or at least, less covered, I actually agree. Why? Because while I am a defender of Chinese medicine, I also agree there are a lot of scams out there! I mean, there are real Chinese medicine charlatans who sell fake cures in the “name” of chinese medicine and I’ve treated patients who are victims of such. Can’t possibly cover THOSE can we?

    Some insurance companies cover acupuncture only for certain diagnoses, like for pain control. i am personally amenable to that.

  30. #30 red rabbit
    November 18, 2009

    I have this conversation with patients regularly: just because your insurance covers it doesn’t mean you need it. You’re driving the cost of your own premiums up if you get the chiropractic, and brand-name drugs that are no better than generic, and insist on new orthotics every year even though the ones you have are perfectly fine.

    I like the Ontario policy of providing cover for the generic. If you want the brand name, pay the difference, you big baby. Rare exceptions, and for those I gladly write a letter for exceptional cover (carbamazepine comes to mind).

  31. #31 Caroline
    November 19, 2009

    I thought you might be interested in “sitting in on” a panel discussion on CER that was held last week in Baltimore. there’s a video of the meeting here:

    http://speakhealth.org/are-there-changes-ahead-for-the-science-of-medicine/

    Feel free to pass it along to colleagues who may be interested, and by all means leave your thoughts.
    ~c

  32. #32 Eamon
    November 21, 2009

    Do bed-bound octogenarians benefit clinically from hip replacement surgery?

    Is this for real? I mean, HPT is so invasive and traumatic that it’s only recently that younger patients have been able to avail of the treatment (in the UK) – and this due to the increasing lifetime of the hip prosthesis. Performing this operation on any octogenarian is ethically challenging, to say the least!

  33. #33 BJ Davis RN, CCRN
    January 8, 2010

    I have been a nurse since we kept heart patients in the recovery room as there were no such things as ICU’s. I go way back.

    I go back to when kids died from appendicitis after they were sent home from the ER with no money for surgery. We had a great county hospital then, the one in today’s article: Jacksom Memorial Hospital. They would never turn anyone away.

    Always; people with insurance were treated differently than those without. After leaving Miami, I saved several lives by using my phone to beg for treatment for poor people. One of my big saves was a two year old that had a seizure disorder. That child was grossly treated by a local private hospital and told to see her private medical doctor. No private medical doctor’s office staff let her make an appointment.

    I know how to get a doc’s private numbers. And they are suckers for a sad story. He rode in on his white horse, made the hospital admit the child, they found an in utero subdural bleed (mind you the child was over 2 years old and more or less moribund on antiseizure medicine)they evacuated the clot and did what they do to make it not rebleed and a miracle happened. The child woke up.

    For years that baby was treated by the local ER and dumped back on the street. She had her sizure meds upped and upped. Why she didn’t die from that I don’t know.

    Within a few months she was chattering like a magpie. Hopping around learning to walk and run. The parents treated me like I was the Queen of England.

    If you can get AT the doctors you may get some help. They are tender hearted folks but they get sued by poor people and they have to put up some kind of gate between them and the lawsuits. Poor people suffer from the greed of the lawyers. Trust me, they do.

    At any rate, what Obama-care will do is put all of us into medicaid insurance and I assure you that is not what private insurance pays for. Your best bet is to find an old nurse with a tender heart and hope she can find a doc with a tender heart and so on and so forth. And there will always be people not receiving maximal care because the do not know the right strings to pull.

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