Health care reform and rationing


Category : Medical Rants


Tuesday’s WSJ has this headline which is meant to scare readers – Obama Will Ration Your Health Care

Given the opportunity, Mr. Daschle would likely charge the board with determining which treatments and drugs are cost effective and therefore permissible to use for patients covered by the government. And because the government is such a big player in the health-care market (46% of health-care spending comes from the government), the board would effectively set parameters for private insurers.

It is nearly certain that the process of determining which drugs and which treatments would be approved for use would be quickly politicized. The details of health-care policy may not be kitchen table conversation, but the fact that a Washington committee can deny grandma a hip replacement due to her age, or your sister a new and expensive drug, is. Health care is personal and voters will pressure lawmakers on access to care.

Liberal experts, Mr. Daschle included, believe that America needs to ration new technology and drugs. In his book, Mr. Daschle complains about overuse of new technology and praises the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), a rationing system that controls government costs. NICE’s denial of care is legendary — from the arthritis drug Abatacept to the lung cancer drug Tarceva. These drugs are effective. It’s just that the bureaucrats don’t consider them cost effective.

We already have health care rationing.  Our current rationing system is covert – DrRich explains this concept on a regular basis, and specifically in this post – Covering "Effective" Medical Services

Please understand that DrRich is not complaining. Such a system, as odious as it sounds, is substantially better than what we have now. Today, we have a healthcare system that claims to cover “everything,” then conducts most of its rationing by coercing doctors to act against the best interests of their patients. Under the system DrRich has just described, a) at least some of the rationing decisions will be made away from the bedside, by the Fed Health, and will be less destructive of the doctor-patient relationship; b) the black and white pronouncements of the Fed Health will not go completely unchallenged, and eventually the feds will have to become more open about their rationing decisions; so c) it is possible to visualize how such a system might evolve, some day, to one where open rationing is conducted under a process of actual transparency.

But DrRich urges his Dear Reader to be less “hopeful” and more skeptical about coverage decisions. If one is mired in hope, then it will be all too easy to just accept on its face the black and white pronouncements of the Fed Health regarding which medical services are “truly effective,” and which are “useless.” Many if not most medical services fall somewhere in between these extremes. Therefore we will need to hold the feds’ feet to the fire to make them accountable for their decisions. Demanding accountability and transparency will eventually yield rationing decisions that are much less bad.

But no matter where or how you draw the line between covered and not-covered medical services, we will still be rationing. And that means that at least some beneficial medical services will always be withheld from at least some people.

For those who have read this far, let me provide the abridged version.  We currently have rationing, albeit often covert rationing.  DrRich and I both believe that open transparent rationing would provide higher quality care to more patients.

Why must we have rationing? Money, we cannot afford to provide every new technology or medicine indiscriminately.  We have actually known of this problem for over 25 years, but now the idea is getting traction.

I am a strong proponent of comparative effectiveness data.  As a physician I need to understand the relative merits of different medications, devices or diagnostic tests.  Unless we demand that appropriate studies compare effectiveness, then we remain at risk for marketing to drive our decision making. 

Too often, we have accepted new medications only to later learn that they really are not better.  We see TV ads encouraging our patients to ask for the newest (and most expensive) treatment.  But we do not really know, because as a society we have not demanded the appropriate studies.

I hope that we can have transparent medical decision making.  Transparency and data would likely lead to voluntary rationing (that and a healthier malpractice environment.)

Why not just let the market place decide?  We have not had a free market in medicine during my career.  Our current medical insurance industry runs current rationing, and patients have no real role in making informed cost-effective decisions. Currently patients want everything, even when everything causes more problems than moderation.  Patients want antibiotics for colds; they want MRIs for simple headaches; they want Nexium (when generic omeprazole is really the same drug.  We need some rationing.

The biggest advantage of a Health Board is that such a board will allow us to avoid some defensive medicine practices.  I only hope that they protect this concept with legal protections.


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Comments (9)

DB, thanks for countering the scare tactics of the WSJ. As you and Dr. Rich point out, we already have rationing, it is just not rational. This leads to a system of the “haves” (concierge,cash only), the “have nots” (insured) and the “have nothings” (uninsured).
Please continue to speak out, because there is going to be a lot more where the WSJ came from. There is a lot of money at stake, and there are a lot of folks with a lot to lose.

At the end of the WSJ piece the author information state “Ms. Pipes, president and CEO of the Pacific Research Institute, is the author of “The Top Ten Myths of American Health Care: A Citizen’s Guide” (Pacific Research Institute, 2008).” Check out the linke from Sourecwatch below. Pacific Research receives funding from Pfizer, PhRMA and the Lily foundation, and some of the board of directors are from med tech companies.

Please check out the

[…] See more here:  DB’s Medical Rants » Health care reform and rationing […]

[…] DB’s Medical Rants » Health care reform and rationing […]

Most health insurance companies, outside of Medicare, ration healthcare. Most companies duplicate each others’ services, require preauthorizations for CTs/MRIs, require extra time calling or faxing in mail order refills, and have extra time spent doing preauthorizations for medications. Generics must be tried prior to brand names; PT must be done prior to approval of MRIs in patients with clear rotator cuff tears who want to see an orthopedic surgeon for surgery without an MRI; copays and deductibles are due at each PT visit or specialty visit to keep patients from doing these serices; physician fees stay constant and actually decrease with the cost of living, while copays and deductible increase. Patients are told they have to see providers in network, or else have no out of network coverage and pay full prices that are often 5-10 times what an insurance compnay would pay. Patients are set on paying about $20 to see a doctor and make a ruckus if the deductible is applied and they owe another $30-$35. The worst HMOs don’t have local specialists in network, as $39.95 for a level three office visit is not much better than Medicaid. Many specialists and primary care doctors refuse to see self paying patients, as the patients don’t pay their bills. Most hospitals take all the insurance plans, but some doctors on staff do not. The current system encourages doctors to see patients with insurance, and people without insurance end up using the emergency departments for their primary care or going without care until the illness is uncontrolled.

I have office visit fees that are within 5-10% of most insurance companies, yet self paying patients feel they should only pay $20 to see a doctor. They often decline to come in as new patients, and established self paying patients want medicines for diabetes, HTN, cholesterol, infections, etc. called in a year at a time without seeing me, as big box discount stores have $10 lists for 90 day supplies of medications. Reports go out about the millions of people without insurance, but many companies offer private polices. Self pay patients take the gamble of not having insurance, but each one saves thousands of dollars from not paying premiums to health insurance companies. The rationing becomes that self paying patients or patients with high deductibles often elect to not do preventive medicine, such as a colonosocpy, PSA, mammogram, stress test, etc. They also elect not to come in for routine monitoring of illnesses, which often are uncontrolled. A patient with a strong PPO insurance company and only a $20 copay is likely to do the recommended care, but a patient with a $5,000 deductible or without insurance is likely not to follow the care plan.

After being in medicine almost 10 years, I wish all patients had access to straight Medicare. Premiums are based on income, usually around $100 a month. Medicare requires no preauthorizations for studies, and rarely do I have any denied claims. Medicare has a small annual deductible and copays that range from $11-$20 per visit. Medicare also does not deny patients with too many illnesses or risk factors. Medicare does not request 2-4 years worth of old records to verify that an illness is not preexisting. To fix the rationing, basic Medicare coverage should be extended to all US Citizens.

I couldn’t agree with you more. We need to weed out payment for useless therapies or those that are marginally better than less costly treatments. While we squander resources on such expensive treatments that have significantly increased costs, we allow more and more of our citizens to go without any health insurance or markedly underinsured; in other words, covert rationing on the basis of economic class. We build medical Taj Majals for those who can afford good insurance while forcing inner city hospitals to survive on a shoe string.

I would point out, as the above comments have, that we already have rationing on the commercial insurance side where it is decided which drugs are preferred on their formulary and in what circumstances you can obtain your MRI. Furthermore, we are not talking about denying care to patients, but offering them the choice of the more cost effective treatment vs the more costly one. There is nothing that denies the patient from chosing the more costly treatment if he/she choses to. He/she simply needs to pay the cost out of pocket. That maore correctly aligns the price of each treatment with its cost rather than what I currently see, which is a patient who says give me the costly procedure or drug since my insurance will cover both and my cost will be the same, so why shouldn’t I take the more costly but marginally better treatment? It will also give medical innovators pause to consider how much they charge for their new product since it will be subject to cost benefit analysis to determine whether its price tag justifies the added cost.

In my experience, if one self-pays, the cost of an office visit is $200 or more. Hardly, the $20 co-pay level…

A Need To Reformulate

The following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care costs are now well over 2 trillion dollars of our gross domestic product. This is three times the amount nearly 20 years ago- and 8 times the amount it was about 30 years ago. Most is spent with medical institutions, as far as health expenditures are concerned. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids.
Our children.
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others.
Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Health Care must be the priority immediately by the new administration and congress. Challenges include the 700 billion dollars that have been pledged with the financial bailout that will occur, since the proposed health care plan of the next administration is projected to cost over a trillion dollars within the first year or so of the proposed plan to recalibrate health care for all of us in the U.S. Yet considering the hundreds of billions of dollars that are speculated to be saved with a reform of the country’s health care system, health policy analysts should not be greatly concerned on the steakholders who may be affected by this reform of our health care system that is desperately needed. Tom Daschle leads this Transition’s Health Policy Team. And we also have Ed Kennedy, the committee chair and a prolific legislator. So if the right people have been selected for this reforming team, the urgency and priority regarding our nation’s health care needs should be rather overt to the country’s citizens.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget.
The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers.
Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if they are numbered correctly to treat and restore others. Also, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.
Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.
Health 2.0, a new healthcare social networking innovation, is informing patients about their symptoms and potential if not possessing various disease states- largely based on the testimonies of other people on various websites. This may be an example of how so many others rely now on health concerns from those who likely are not medical specialists, instead of becoming a participant, if not victim, of the U.S. Health Care System.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.
Dan Abshear

I have heard that is possible to have recto-cranial conjunction, but I have never observed it until now, judging from some of the replies you have made. You might think that I have that condition, but at least I am not willing for some non-medical bureaucrat to tell me how to practice medicine, what I may not do for my elderly patients and whom I have to withhold needed care from. Cost-benefit analysis might be OK for manufacturing, but it has little relevance in caring for my patients. The thought that I might have to tell a patient in kidney failure that dialysis is forbidden to him or her, or that needed orthopedic care and MRI studies can’t be provided makes me sick to think about it. Dr. Abshear, et al. need to quit drinking the KoolAid and look into the real world. You people are appeasers, medical Chamberlains. Churchill said that “appeasement is similar to being nice to an alligator so that he will eat you last!” What is next? Assisted suicide, such as Oregon now provides?

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