Wednesday, June 3, 2009

Rationing? Or intelligent use of resources?

We keep hearing a lot about how any health care reform will necessarily involve some form of "rationing". The Whigs, I mean Republican Party, would have us believe that Obamacare will lead to Soviet bread line-style rationing of health care. Just you wait; you'll be standing in serpentine Disneyland-type lines jagging back and forth with a bunch of other people with appendicitis waiting to get surgery, so they imply.

I hate this kind of garbage. "Rationing" is such a loaded word that carries collectivist connotations of delayed care and loss of autonomy. We hear about rationed health care and everyone wants to march against the tsar. But we have a disturbing tendency nowadays to overuse and/or misuse terminology in our political/cultural discourses. Sotomayor is a racist. Obama is a socialist. Iran is evil. It's ridiculous. These are important words with very specific meanings and contexts. Throwing them around while ad libbing on a Fox News pundit panel is just irresponsible and intellectually dishonest.

There's a difference between rationing and intelligent use of healthcare resources. No one is talking about making patients wait 6 months for a heart bypass. Obama isn't going to deny your laparoscopic cholecystectomy if you come into the ER with acute cholecystitis. At issue is the overutilization of expensive, limited resources. Should a 90 year old demented patient be kept on a vent in the ICU with every other day dialysis? Does every morbidly obese 55 year old with cranky knees (but is still ambulatory and able to work) need bilateral titanium knee replacements? Does every woman with breast cancer need a breast MRI? Do we need $5 million DaVinci robots in every hospital?

We're not talking about rationing the staples of health care provision (preventative care, emergency/oncologic surgery, etc). What needs to be trimmed are the extraneous goodies that coincidentally tend to make the most money for hospitals and providers. Not everyone admitted to the hospital with indigestion needs upper and lower endoscopy. Not every chest pain needs a heart catheterization. Not everyone with aymptomatic gallstones needs a lap chole.

There's a difference between trimming excess fat and limiting basic necessities. True rationing (food in wartime, gasoline in an oil shock) forces us to cut back on the basic stock we depend on for subsistence. Cutting back on luxury items is not rationing; it's just smart economic behavior. We need to do an honest accounting of what is truly necessary in medicine. It won't be easy. Tough decisions lay ahead. But calling any form of healthcare cost containment "rationing" or "social medicine" is just ridiculous political grandstanding.


Joseph Sucher, MD FACS said...

This is an easy post to agree with. But the challenge remains: What is "rationing" to some is an appropriate allocation of resources to another.

We in health care continue to see the demand from our patients that we "do everything" that can be done (regardless of the outcome). It's a very different world that we live in today versus the 1940s-80s. Much has changed in the culture that I consider parallels the Internet. That is: there is a significant population that demands something for nothing and expects it immediately and without error. This has made an impact on how we practice.

A simplistic example - I haven't missed an appendicitis nor taken out a normal appendix in 8 years. This is clearly a change from an accepted "negative appy" rate of 15-20%. Why has this changed. Because society demands that we don't operate on people who don't need it. They expect us to get the correct diagnosis the first time using the least invasive measures available to us. We are held to a higher standard. This, I believe, is part of the reason why health care expense continues to rise. We spend more to achieve the demands of society.

The recent Atul Guwande article in the New Yorker is certainly a good read as it relates to this topic. He expounds on the waste driven by physicians who work the medical system as a business and slams the doctors and hospitals of McAllen, Texas. I think an important point about this article that wasn't discussed nearly enough is that we must have definitive standards of care before we will ever be able to reign in the spending.

This gets us back to your post. How will we make these tough decisions on who should get knee replacements, and who should or shouldn't be on dialysis, and who needs a cholecystectomy. Your examples seem very clear, but I wager to bet that if you tried to define who should and who shouldn't get something, you would find yourself in a tussle with an angry mob. You would be right, of course. But it wouldn't make the fight any less hard or bitter.

We need to improve this broken system. And you are so darn right to point out the need to stop this name calling game. I hope that cool heads prevail and find out how to get us back on the right track.


Anonymous said...

You left out "should a 77 year old alcoholic U.S. Senator with an unresectable Glioma suck up however many hundreds of thousands of precious Health Care dollars he has for a terminal illness?" I left out the part about how he flew down to North Carolina...don't they have a hospital in Bahhhh-ston??? You could buy alot of amoxicillin for whats been spent this guy...

Bianca Castafiore? said...

Buckeye Surgeon, I am happy to serve as the naive and simpleminded layperson, who just plain appreciates the good sense of your post.

It's "easy to agree with" for a reason unfathomable to Joseph Sucher, MD FACS, who apparently would prefer to tease the thin, brittle, *tired* strands of non-argument!

One almost wants to yell that he "grow a pair" but that might be misconstrued as unduly critical or -- worse -- yet another societal demand.

He and most medical bloggers are right to descry the demand of "something for nothing"? That has to, and will, change. No way around it. But what may pose a big problem for some {whistle whistle} does not for most. All my treating doctors are perfectly able of providing good treatment without caving in to some purportedly irresistible demand I might come up with. Like some totally unnecessary procedure. [?] Or the funky requests I read about happening in EDs/ERs, like the insistance on a midnight pregnancy test.

Or like, say, "don't take out my appendix unless it truly is diseased." The gall! The nerve!

A return to the mindset that would tolerate a "negative appy" rate of up to 20%? To wink at the dangers of general anesthesia and the rare -- but real -- complications of invasive procedures? Sorry, Dr. Sucher, but that is hardly an unrealistic demand of "society."

Normally, I would mention greed about now, but that cannot be a factor, what with y'all being held to a higher standard 'n all.

Dr. S., you are on to something, though, when you say: "I think an important point about this article that wasn't discussed nearly enough is that we must have definitive standards of care before we will ever be able to reign in the spending." H-E-L-L-O! You are confusing my simple self! Isn't that precisely what is being proposed within the Obama health care reform initiative?

The response to this among the more conservative medical bloggers has been a sort of "Jump back! No way is big government gonna tell moi what to do!" -- which is, of course, not what is being proposed.

So glad to see that Joseph Sucher, MD FACS, will be actively promoting reform. That gives the little people such a sense of peace.

Joseph Sucher, MD FACS said...


That's a fascinatingly erratic diatribe befitting the melodramatic character by which your are named. I believe that you read my posting in the simpleminded way by which you self-describe.

However, since I had no idea that my words would be twisted in such a way as to appear nearly the opposite of what I intended, I will recap (hopefully without teasing the tired thin strands of this non-argument).

In fact, I was not arguing at all, but trying to enlighten based on my own struggles with the realities of the practice and business of health care. I am fortunate to work in an academic environment where all the resources imaginable are immediately available; and necessarily so, as my mission is to care for the sickest surgical patients in and around SouthEast Texas. I see every single day the errors caused by omission and commission from physicians of all skill levels.

First, my example of how appendectomy attitudes have changed was meant to show one reason why health care cost has increased. I did not mean to imply that reducing the "negative appy" rate was bad, and in-fact I published on this topic in 2002 describing imaging modalities for acute abdominal pain. You need to know that, in fact, many surgeons still argue that a 20% negative appy rate should still be considered standard of care. I disagree. However, using advanced imaging comes at a cost. This cost has impacted health care negatively.

Second, you are placing your attitudes and judgement into this discussion believing that you represent the norm of society. However, I am generalizing a cultural shift that may not represent who you are. This culture expects more for less. This has impacted medicine further increasing the costs as physicians practice more defensive medicine (this is a well described phenomena and does not represent how I practice or your particular doctors treat you). I can just tell you that medicine becomes extraordinarily more complex past the simple examples of gallbladders and appendices. I practice as a surgical intensivist, caring not only for my own surgical patients, but for many other surgeons. I see huge expenditures of resources that some could easily call wasteful... But the problem is that when it comes down to individual patients it gets very personal. I've cared for patients that have spent months and even over a year in the ICU. Some of those people have indeed come and seen me one, two, three and more years later. Walking, talking, smiling, productive. Incredible. The problem... when those people were sick and dying with predicted mortalities of 95%+ and everyone was telling me to give up.. there was no way for me to tell if I that one individual would make it. So who is going to make the call on who I should spend the resources on and who I should not? That's going to be a tough job.

Believe me when I say. I am committed to excellent, safe and effective care. I push standards of care. I sit on multiple patient safety committees. I am part of a research team creating complex methods of computerized clinical decision support. But all this being said, I've learned in medicine (and while I served in the Army) that a frontal assault on an entrenched enemy is folly. You may see that as needing to "grow a pair". I see it as ensuring that I maintain open discussions without the name calling. Just as I ended my last post.

I hope this clears up my obviously obtuse original post.


Jeffrey Parks MD FACS said...

You left a dripping trail of sarcasm/contempt on your way through....I'll clean it up. Ought to be nicer to ol' Doc Sucher though. He's not so bad for an academic surgeon.

Public demands for greater efficacy/excellence can have a positive effect, no? Laparoscopy took off prior to any accumulation of scientific evidence that could support it. By the same token, how we define "disease" depends to a large extent on public perception, which isn't always a good thing. Abdominal pain is now problem that is furiously worked up on an inpatient basis until some "diagnosis" is arrived at. Patients spend days in the hospital getting scoped, going to MRI, getting CT scans, drinking enough radioactive barium to light up when seen from space, meeting 6 different consultants, getting bloodwork sent off....and the diagnosis remains elusive. Or maybe the US shows a few gallstones. So they get their gallbladder out and everyone feels better. Soemthing was DONE. That's the mentality we need to rectify.

Anonymous said...

If you have "good insurance", as I do, cutting back availability of services (even luxury services) is not something you look forward to. I had a procedure earlier this year that some would consider a luxury (catheter based RF ablation of a supraventricular tachycardia) - I certainly would not have had it performed had I not had insurance. On the other hand, you realize the costs of the system as it currently is not sustainable and people without insurance need it (i.e., our society ought to do better for all citizens). The thought that President Obama communicated during the election campaign regarding his healthcare plan ("if you have health insurance and are happy with it, you can keep it") versus a mandatory single payor system sounds attractive to me.

HMS said...

"Some 62% of all bankruptcies filed in 2007 were due in part to medical expenses, according to a new study. Even more striking: 78% of those individuals had insurance," according to WSJ article.

It helps to wonder what's wrong with this [uniquely American] picture. I guess somehow medicine* costs a lot more in US that it does elsewhere.

* AND everything else?

Stephen said...

Humans have a nagging will to keep on living. The free enterprise system keeps producing new drugs and procedures that allow people to keep on living. This creates a truely insatiable demand for health care.

Now, anything with an unlimited demand and limited supply is going to have to be rationed by some mechanism. Today, it's rationed by money. Those who can afford the newest whiz-bang drugs and procedures (or those who can afford 'insurance' to do so) pay the premium. Those who can't, don't. There is a perception that those who do pay the premium live longer (whether that perception is true or not can be debated elsewhere).

Certain politicians make the case that the current system is unfair, and that everyone is 'entitled to healthcare.' That is to say, the current rationing system is morally unacceptable. I would contest that premise, but let's continue. What are the alternatives?

I see two. In either case, you have to restrict the supply side of the equation, since the healthcare demand is impossibly great. In short, you could ration supply based on the patient or based on the treatment. Or maybe some combination of the two.

You could ration by some other means, presumably government imposed cost-benefit analysis, taking patient information into the equation. Couple issues there. First, like all things government, it would be bureacratically slow and plagued by corruption (note: I used to work in government). Second, you would to have the government actively denying care to some patients, in order to free resources for 'more worthy' patients. Best case, you'd create a black market for medical care. Worst case, the bureaucrat could be said to have jeopardized my life, with resultant moral justification to employ countermeasures against the bureaucrats.

The other option would ration treatment, based only on the efficacy of the treatment. While allowing for evolutionary perfection of existing techniques, it does promote wide, cheap availablility. But it would severely restrict the ability of revolutionary new treatments to make it to market. For example, laproscopy would never have become mainstream. Early laprospopy was notoriously expensive. It was those patients who sought out the technique, and shouldered the premium, that financed its widespread adoption today. So rationing this way incurs consequences on future generations of patients, although it might arguably limit the risk of black markets.

All that to say, I think I prefer my current system best: a health savings account with a true Catastrophic insurance policy. At least I can determine my own level of care. I just have to accept the deadly risk of underestimating my future health costs.

Nurse Irene said...

I am a registered nurse who's specialty is geriatrics. It is a disgrace to see so much money spent to save old lives. These people generally have Medicare or Medicaid, and most facilities are happy to spend it all for someone who will not live more than a few weeks at best. The families of a lot of these patients have unrealistic expectations, and when told that their loved one is going to die, they want everything done to prevent it from happening, no matter how painful or invasive. I have had to explain the effects of CPR on a frail 90 yr old to families, and the fact that it is only helpful in 20% of most cases anyhow, even when performed on young healthy people. Many of the people that I have cared for had no health insurance when they were younger, but were able to get Medicare or Medicaid when they turned 65. That means that they generally did not get physicals or other preventative care until they were old, and now that they have insurance, they want it all, and at once.

I don't agree that common sense allocation of medical resourses is "rationing". We all get old and die.

I want to see a program that treats all people of all ages so that we don't get stuck with a bill for saving the old dying and near dead, as I now see. If people get regular care, they will not be so sick when they do get old. That would be a huge savings in what is spent now.

Anonymous said...

What's the "cost/value" of life?
Can we really put a price tag on life?

If our society and medical establishment could put more emphasis on family value, education and primary & preventive medicine, we wouldn't be forced to walk on such a tight rope.