Medicine: Who Decides?

[jebus]

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For your reading pleasure (& for those who don't pay for the NYTimes Select):

Health care seems to be heading back to the top of the political agenda, and not a moment too soon. Employer-based health insurance is unraveling, Medicaid is under severe pressure, and vast Medicare costs loom on the horizon. Something must be done.

But to get health reform right, we'll have to overcome wrongheaded ideas as well as powerful special interests. For decades we've been lectured on the evils of big government and the glories of the private sector. Yet health reform is a job for the public sector, which already pays most of the bills directly or indirectly and sooner or later will have to make key decisions about medical treatment.

That's the conclusion of an important new study from the Brookings Institution, "Can We Say No?" I'll write more about that study another time, but for now let me give my own take on the issue.

Consider what happens when a new drug or other therapy becomes available. Let's assume that the new therapy is more effective in some cases than existing therapies - that is, it isn't just a me-too drug that duplicates what we already have - but that the advantage isn't overwhelming. On the other hand, it's a lot more expensive than current treatments. Who decides whether patients receive the new therapy?

We've traditionally relied on doctors to make such decisions. But the rise of medical technology means that there are far more ways to spend money on health care than there were in the past. This makes so-called "flat of the curve" medicine, in which doctors call for every procedure that might be of medical benefit, increasingly expensive.

Moreover, the high-technology nature of modern medical spending has given rise to a powerful medical-industrial complex that seeks to influence doctors' decisions. Let's hope that extreme cases like the one reported in The Times a few months ago, in which surgeons systematically used the devices of companies that paid them consulting fees, are exceptions. Still, the drug companies in particular spend more marketing their products to doctors than they do developing those products in the first place. They wouldn't do that if doctors were immune to persuasion.

So if costs are to be controlled, someone has to act as a referee on doctors' medical decisions. During the 1990's it seemed, briefly, as if private H.M.O.'s could play that role. But then there was a public backlash. It turns out that even in America, with its faith in the free market, people don't trust for-profit corporations to make decisions about their health.

Despite the failure of the attempt to control costs with H.M.O.'s, conservatives continue to believe that the magic of the private sector will provide the answer. (There must be a pony in there somewhere.) Their latest big idea is health savings accounts, which are supposed to induce "cost sharing" - that is, individuals will rely less on insurance, pay a larger share of their medical costs out of pocket and make their own decisions about care.

In practice, the health savings accounts created by the 2003 Medicare law will serve primarily as tax shelters for the wealthy. But let's put justified cynicism about Bush administration policies aside: is giving individuals responsibility for their own health spending really the answer to rising costs? No.

For one thing, insurance will always cover the really big expenses. We're not going to have a system in which people pay for heart surgery out of their health savings accounts and save money by choosing cheaper procedures. And that's not an unfair example. The Brookings study puts it this way: "Most health costs are incurred by a small proportion of the population whose expenses greatly exceed plausible limits on out-of-pocket spending."

Moreover, it's neither fair nor realistic to expect ordinary citizens to have enough medical expertise to make life-or-death decisions about their own treatment. A well-known experiment with alternative health insurance schemes, carried out by the RAND Corporation, found that when individuals pay a higher share of medical costs out of pocket, they cut back on necessary as well as unnecessary health spending.

So cost-sharing, like H.M.O.'s, is a detour from real health care reform. Eventually, we'll have to accept the fact that there's no magic in the private sector, and that health care - including the decision about what treatment is provided - is a public responsibility.

 

[rachmoninov3]

First let me apologize for the flaming libertarian/conservitive smut that will follow:

The NY times is liberal...first and foremost.

WHO DECIDES?

I believe that all hospitals should be nonprofits who do not care about competition, but hey, I'm living in a dream world...and actually I currently am. I grew up in Phoenix where Banner, JC Lincoln, and Catholic Healthcare West were all in competition with each other. Who has the neurologic center...who has the best pediatrics...who is best for cancer...who has nicer facilities...and my personal favorite: who is the catholic hospital?

Today I live in northern new mexico and work for a independant, non profit hospital who is the biggest thing north of albuquerque and south of denver. We take anyone regardless if they can pay, and only fly out stabilized premies and traumas that need go to UNMH. Most of our patients can't and don't pay for their treatments, but the hospital is able to run thanks to government grants ($5M for sole-provider) and an active hospital foundation. The decisions about my patient's care is left to them and their assigned hospitalist or the La Familia family practice which is part of our ER-Hospitalist-Primary Care set-up (and of course medicare/medicaid to a certain extent.)

This is the most ideal, working healthcare situation I have encountered. I believe it works because instead of trying to change how a large mass of people from all different economic, educational, and social backgrounds view their health, a hospital changes for it's population. For instance, we have a primary care practice 25 feet from our ED, that sees walkins and appointments alike. Instead of hounding those who can't pay their bills, we have expanding the hospital foundation in order to raise more money to care for the uninsurred/underinsurred.

I understand that this would never work in a large city where there is competition for patient care, however, it is ideal in that it keeps the desicions primarilly between the patient and physician.

If government is to do anything for healthcare there should be more grants for hospitals to cover underinsurred/uninsurred individuals, and to give more tax breaks to encourage donating to hospital foundations.

and one last thing: HEALTHCARE SHOULD CHANGE FOR THE INDIVIDUAL, NOT THE INDIVDUAL FOR HEALTHCARE...IT'S SO MUCH EASIER TO CHANGE THE MINDS OF AN ORGANIZATION THAN IT IS TO CHANGE THE MINDS OF A DIVERSE AND LARGE POPULATION.

 

[jebus]

I have nothing to add, but I live in Albuquerque. WhooO! NM! Yay! (I used to work at UNM HSC. Well, doing research, but I ate at med II occasionally.)

 

[chef_NU]

The Brookings study puts it this way: "Most health costs are incurred by a small proportion of the population whose expenses greatly exceed plausible limits on out-of-pocket spending."

Right, so the answer is to let insurance companies cater to the majority of the population - the low risk people. Then the vast majority of people have low health insurance costs, and the people who are the hopeless parasites get screwed. If insurance becomes corrupt/outlandish/high-cost/high-profit, the majority of the low-risk population can just drop insurance and pay out-of-pocket expenses. There's no reason to burden the rest of the population with treatment that simply isn't justified economically. There was a study done that said that something like 2% of Medicare recipients yield 35% of costs. That, to me, is dumb.

 

[QuantumMechanic]

Right, so the answer is to let insurance companies cater to the majority of the population - the low risk people. Then the vast majority of people have low health insurance costs, and the people who are the hopeless parasites get screwed. If insurance becomes corrupt/outlandish/high-cost/high-profit, the majority of the low-risk population can just drop insurance and pay out-of-pocket expenses. There's no reason to burden the rest of the population with treatment that simply isn't justified economically. There was a study done that said that something like 2% of Medicare recipients yield 35% of costs. That, to me, is dumb.

So who's gonna pay???? The answer has to be insurance inclusive to highrisk people, charity, or the government. There's no free lunches as they say in Econ 101, but we as a society have already made a decision not to deny costly, yet lifesaving medical care (things like heart surgeries, truly lifesaving procedures) to those who can't pay.

 

[chef_NU]

So who's gonna pay???? The answer has to be insurance inclusive to highrisk people, charity, or the government. There's no free lunches as they say in Econ 101, but we as a society have already made a decision not to deny costly, yet lifesaving medical care (things like heart surgeries, truly lifesaving procedures) to those who can't pay.

No one pays. You say there's no free lunch. You're right. For certain individuals, there is no lunch.

 

[QuantumMechanic]

No one pays. You say there's no free lunch. You're right. For certain individuals, there is no lunch.

That's a perfectly valid viewpoint, but like I said, our society has made the decision, for better or for worse, to provide lifesaving (which usually becomes expensive) healthcare to the indigent and elderly population. I cannot see this changing in the future, especially in terms of medicare since so many old people vote and demand full medicare coverage. Thus, the lunch will be provided, at your cost, whether you like it or not!!!!

 

[Gut Shot]

That's a perfectly valid viewpoint, but like I said, our society has made the decision, for better or for worse, to provide lifesaving (which usually becomes expensive) healthcare to the indigent and elderly population. I cannot see this changing in the future, especially in terms of medicare since so many old people vote and demand full medicare coverage. Thus, the lunch will be provided, at your cost, whether you like it or not!!!!

I'm actually okay with it, since I'm planning on being elderly someday. Besides, to qualify for Medicare benefits one has to pay into the system via payroll taxes for at least 10 years (I think). Oh, and Medicare pays virtually all resident salaries, which is just super. Thanks for the paycheck, go Medicare!

 

[QuantumMechanic]

I'm actually okay with it, since I'm planning on being elderly someday. Besides, to qualify for Medicare benefits one has to pay into the system via payroll taxes for at least 10 years (I think). Oh, and Medicare pays virtually all resident salaries, which is just super. Thanks for the paycheck, go Medicare!

Nope, you just have to be over 65 or disabled to get medicare. Its not like a retirement benefit that is earned through past work credits, currently its an unearned entitlement given to elderly and disabled citizens.

 

[Gut Shot]

Nope, you just have to be over 65 or disabled to get medicare. Its not like a retirement benefit that is earned through past work credits, currently its an unearned entitlement given to elderly and disabled citizens.

From the AARP:

"Medicare covers all who qualify, regardless of age, medical condition, or ability to pay. At age 65, individuals qualify for Medicare Part A if either they or their spouse paid into the Social Security or Railroad Retirement system for at least 40 calendar-year quarters (at least ten years of work). No premium is required for enrollment in Part A because beneficiaries paid into the system during their working years; those who lack sufficient work history may purchase Part A coverage. Individuals qualify for Medicare Part B upon turning 65; if they wish, they may enroll in Part B by paying the monthly Part B premium."