What are the different ways to ration medical care?
A blogger asked the question on when it was OK not to take care of patients because of conscience. I suggested that patients are free to do as they please, but shouldn't expect others to pay for their poor choices.
A blogger asked the question on when it was OK not to take care of patients because of conscience. I suggested that patients are free to do as they please, but shouldn't expect others to pay for their poor choices.
The suggestion here is that America should pay to take care of everyone, no matter how they got where they are. "Maybe we should take care of sick people no matter how they got that way."
In a world of snow angels and sugar plums this would be the ultimate social utopia. I would want nothing more than to know that if I became ill, that I would have an unlimited supply of FREE=MORE health care for which to feel secure. I am no different than anyone else. I love free Sam's Club food samples. I love 99 cent gas giveaways. I love getting free movie coupons from Blockbuster.
But, I also know that this social utopia is not achievable. The grand experiment called The Medicare National Bank (MNB)has proven it. The MNB promises its depositors everything (minus a denied lab draw or a port -a-potty here and there). A key word here and there in the documentation road race and everything under sun is paid for. It is the sham known as "medical necessity". I could make a healthy 65 year old with no medical problems get any test in the world by playing the "medical necessity" documentation game. The game for which all of the MNB's payments are based on.
The MNB is a financial black hole who's unfunded mandates are more than 10 times the trillions of dollars our government is currently printing to prop up worthless assets associated with the likes of Lehman Brothers (the former), AIG, Citibank and B of A put together. The Medicare crisis is so much larger than the current financial collapse that comparisons are nearly unfathomable.
The promise of "we should take care of sick people no matter how they got that way" is not achievable going forward. Perhaps in a world where medical care for sick people was to diet and exercise and maybe one or two pills and to go home and die. That's not the current reality. The current FREE=MORE reality means that eventually, as the money spigot of the MNB runs out, FREE=MORE will become MORE=LESS. We will have no money to pay for care. End of story. The failure of the MNB will be the largest bank failure ever in the history of the world. it will take down 15% of America's GDP in one massive swoop.
This is the current reality.
Medicare's FREE=MORE party will have to end, and soon. If the unfunded mandates are ten's of trillions of dollars for only 50 million people in the current Medicare Utopia, the task of expanding "we should take care of sick people no matter how they got that way" to 300 million people would be like giving a million dollar subprime mortgage to every Tom Dick and Harry in this country and believing in your heart of hearts that they really will pay it off. We see what happened with that.
FREE=MORE for 300 million entitled Americans will never work.
The rapidly rising private premiums for both individuals and businesses and their inability to afford them is proof positive that the "we should take care of sick people no matter how they got that way" mantra is unsustainable. We have done it. It has failed. Soon, we will have money for no one.
There isn't a Ponzi scheme in the world that could sustain the FREE=MORE position And because it's not achievable, we will have to accept other limits on care in one way or another. Our current rationing system is not enough.
There are many ways we currently ration care. What are the different ways to ration medical care?
- Time. Prevent access by creating waiting lines.
- Price. Witness the collapse of primary care. Prevent access by paying too little for the service. Also witness the explosion of procedural based, surgical based care.
- Insurance. If you can't afford the care, you get no access. I think, however, that if the 85% of the population provided adequate payment based on price, the 15% would be absorbed by charity care. As it stands now, all care (non surgical/non procedural) is a form of charity care
In any of the above ration scenarios, we fail to "take care of sick people no matter how they got there". People die and get worse from all three scenarios. But it's still not enough.
There are other ways to ration care. I can assure you, that as the shit hits the fan, no stone will be left unturned. At some point, the Medicare National Bank will have to be recapitalized. Whether that means massive tax hikes on everyone or vastly decreasing services, or both, eventually the MNB will be called home on their fiscal irresponsibility. So how else can you ration care?
- Disease. If you have certain stages of disease, you are denied care from the MNB. Metastatic cancer? End stage COPD? End stage CHF? Alzheimer's? Name your poison. There are many diseases that cheat death. At some point, the MNB will have to come to terms with the possibility of rationing care based on disease. Be prepared for this possibility.
- Age. Too old for dialysis? Too old for an ICD? Too old for an ICU hospital admission? It will have to be discussed. Decisions will be made. Rationing of resources will be made. Be prepared for this possibility.
- Lifestyle. If you smoke, be prepared to be denied access. If you do crack, be prepared to be denied coverage. If you fail to join lifestyle modification classes or fail to show improvement in basic exercise tolerance tests, be prepared to be denied coverage or pay more for lifestyle associated disease process. Rationing of resources will be made. Be prepared for this possibility. We already deny liver transplants to those actively drinking. Scarcity of resources we say. Of course the MNB is a scarce resource already, we simply chose to look the other way. At some point we will have to look back and stare rationing down right between the eyes and deny coverage for poor lifestyle choices.
I don't live in a fantasy world. I know that "Maybe we should take care of sick people no matter how they got that way?" is not an answer to the problem, except when you're frolicking with fairy princesses. In a world where resource utilization will truly have to be rationed, we will have to pick one, two or all three of these future rationing tools. I pick personal responsibility. That's just me.
And that's also why I'm constantly saying that you have to start now to take the best care of yourself that you possibly can. Because in the not to distant future, there will be no money left to help you overcome things that you could have prevented. And the money that's left will be rationed. And you will get denied care for things you brought upon yourself. You think trying to get a liver transplant now is hard. Wait until the MNB collapses in a blaze of glory.
And you will have no one to blame but yourself for your failure to act now. Lifestyle rationing is my poison. What's yours?
I see both of your points. There obviously has to be some responsibility taken by patients - this can be incentivised by some sort of credits or cheaper outlay when one quits smoking, loses weight, achieves better BP control, etc. Or by "sin taxes". However, you can't just judge everyone by their bad decisions and elect what to treat and what not to treat. As she said, something like going down an expert ski slope when you are only a beginner is pretty dumb but you can't deny them care when they break their neck.
ReplyDeletePretend you are a dentist or a vet. Would you give a shit about how either "patient" came to see you or for what problem?
ReplyDeletePink, the problem with wanting to "not muck up the proverbial garden" is that people absolutely insist that "medicine is different."
ReplyDeleteWhen I recently decided I could no longer afford to take Medi-Cal as a form of payment at my practice, because I'm going bankrupt, angry social workers screamed at me that I was "abandoning the patients." I wasn't--I was just expecting people to cover their $130 deductible that MediCare doesn't cover. Some of them are willing to do that, and some arent't (or aren't able to.
The patients have been enculturated to expect that their care is "free." It isn't. And when the large entities are not there to pay for, it's either going to have to come from the patients' pockets, or it's not coming.
But the patients still expect to be treated. Despite a quarter-million of training debt that I'm expected to pay back, and insurers that have continued to cut my pay 40-50% as a primary internist, I'm still expected to keep giving and giving. I guess I'm not supposed to worry my pretty little head about paying my bills--but despite working 85 hour weeks and having 6 days off a year, I cannot pay myself. And patients are still expecting me to see them for free, or just "write off" the deductible.
People in this country treat health care as a right, not a service that costs money and whose availability depends on the sweat and blood and personal sacrifices of those of us doing the work.
Rationing already occurs based on insurance coverage as Happy notes. I posted about this on my blog a week or two back, but other countries with nationalized systems ration care as well. When one realizes that 80% of a persons healthcare spending occurs in the last two years of life, it is not hard to see that with spiraling healthcare costs...(6.7% per annum) this will be a necessary discussion in the future.
ReplyDelete"Bianca, one cannot talk about the 'moral obligation to treat' without also talking about the economics of providing that morality."
ReplyDeleteSure I can. Oh, I see, you just didn't express yourself clearly. Kind of like that lazy-assed fat suicidal patient...
"The two cannot be separated. You cannot take care of sick people without money."
No -- *you* cannot take care of sick people without money. I've actually seen it done.
And, of course, my cards ought to be on the table: I believe that capitalism and healthcare don't belong hand-in-hand. Disclosure: I have a link to the "parti socialiste" over at my place...
Socialism as ever-in-flux and in need of improvement -- not your scary static dirty-word socialism.
"Morals or otherwise. Sick people cost money. My position has always been health care is about money."
D'uh! I think I speak for Pink when I say: We know that, Hapster. So stop trying to verbally fudge up your presentations with allusions to morality.
"Just as everything else in our world is."
Money. (Social) Morality. Both are CONSTRUCTS. So change the construct into which you "buy." It can be done.
The poison I would choose, Happy? It would kill you [as you present today, at least].
We already ration care -- as you point out in ins. coverage; in transplant decisions; in clinical trials; by racism; by classism; and in hundreds of other ways. What we do not do? And herein lies your tremendous worth as a blogger -- what we do not do is TALK ABOUT IT or dare to CODIFY IT. As long as we begin to do that, the terror of the unique American combo of Nazism & the New Deal can be waylaid. But we are running out of time and definitely out of good will.
Bianca,
ReplyDeleteHow, exactly, do we ration health care by racism? There are many studies demonstrating racial differences is outcomes, but none that demonstate that those differences are CAUSED (not correlated) by access. What data do you have that RACE alone (not culture, not SES) is a mechanism of rationing? If you mean by rationing trough race you mean SES then you really mean rationing by money. The issue of race and SES is a different issue and irrelevent to the health care discussion.
What is the "Asian paradox?"
ReplyDeleteMarco
I can picture your healthcare world where the patients are huddled in a line frantically searching their minds for any indiscretions that might jeopardize their access...kinda of like seinfeld's sponge worthy episode. Or perhaps a modern day spanish inquisition...did you or did you not worship at the altar of the treadmill and raw vegetables? Albert Scweitzer, doctors without borders, I guess they're saps or enablers. To take your arguement to the extreme. I guess you could just watch that COPDer suffocate to death and then sleep like a baby. No disagreement that medicare needs to be reworked and people should take more responsibiility for their part of the health equation. But to sit as judge, jury and executioner, I don't think that was in the hippocratic oath.
ReplyDeleteMidwest woman,
ReplyDeleteThe point is not that care is denied based on one's actions. The point is the feeling by many Americans that regardless of their actions, that they are entitled, for free, to the products of others labor. Would you continue to go to work if you were not paid for your labor? Would you forgo the care of your family (food shelter, clothing) so that other people can behave however they want and demand your services? By the way, I am quite tired of references to the Hippocratic Oath demanding that I give my services for free. The Hippocratic Oath ALSO states that medical education should be given for free and yet I have a bill for $100,000 that says my education wasn't free. And which hippocratic oath are you referring to? Read it before you spout off about that which you know nothing.
Happy,
ReplyDeleteOne of your favorite Phrases seems to be the FREE=MORE mantra. If this is true, how come we seem to pay more for our health care here in the US than any of the other industrialized countries in the world that have goverment paid health care. Most have minimal up front costs for their population whcih amount to free I guess, although they presumably pay taxes to support their systems. Please explain?
First of all the original post was about refusing to care for the chronically ill who choose behaviors that exacerbate their dieases. Second of all I think your debt load is outrageous especially when college coaches get multimillion dollar contracts and the the finacial pig at the trough scenario is playing out on capitol hill while your reimbursemants are decling, the unfunded mandates are skyrocketing and you get no assistance to be trained in one of most necessary professions of the face of the earth. I don't expect you to work for free. I hate taking care of the non-compliant frequent flyers and the full codes whose time has come and gone. Having said that, what exactly are we supposed to do as healthcare providers right now? A stand alone post..not sure what that means but it doesn't sound good.
ReplyDeleteIn a backhanded sort of way I'm agreeing with you. I didn't say you were actually refusing care but the original post did pose the question is this something to be considered in light of cost efeectiveness economics. You are right in that people do not change a behavior till they feel consequence...that's human nature.I think people will change the way they view it but a social mentality does not happen overnight. I'll tell you what I see as a geriatric nurse. For example, wound prevention is huge in this population. We buy specialty beds and mattresses and the cost is exorbitant. Fecal management systems for c diff (a piece of plastic with an inflatable balloon to hold it in place...a rectal foley)400 bucks!!! I will tell you the foxes are circling the medicare chicken house and eating quite well. There might be more in the Medicare bank if the carpetbaggers hadn't come to town to make a quick buck. And they are out there. What about containing supplier costs?
ReplyDeleteBianca,
ReplyDeleteHow, exactly, do we ration health care by racism? There are many studies demonstrating racial differences is outcomes, but none that demonstate that those differences are CAUSED (not correlated) by access. What data do you have that RACE alone (not culture, not SES) is a mechanism of rationing? If you mean by rationing trough race you mean SES then you really mean rationing by money. The issue of race and SES is a different issue and irrelevent to the health care discussion.
Hi, Ohio Oncologist. My, you really want to rename the problem. Whatever (as the kids say). If you are jonesing for some scholarship, just go to PubMed and plug in "racism" as your search term. No, don't change the term! Then pick and choose until the Data Urge has been scratched. I don't think there is any one in the United States who would argue that the marginalization of minority (racial/ethnic) populations does not inherently involve an institutional level of racism (the only level we're comfortable talking about). Good thing that's not my point, eh? The 2004 Institute of Medicine report, "Unequal Treatment," nicely differentiates between "adverse social determinants" and "disproportionate representation among the uninsured" and posits the less obvious point: "In the last twenty years, however, the literature has highlighted the fact that racial and ethnic disparities occur not only in health, but also in health care."
http://www.ncbi.nlm.nih.gov/pubmed/15543432?
There's also some interesting reading from plugging in one of the co-authors: Joseph Betancourt of The Disparities Solutions Center at Massachusetts General Hospital. He's done nice work.
I bet you would better stomach one of his articles -- titled:Personal Responsibility Versus Responsible Options: Health Care, Community Health Promotion, and the Battle Against Chronic Disease
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1955416
I do believe that the code word in medicine -- the acceptable way to talk about racism without saying so -- is to speak of "community health." Much as my "urban" high school is actually a school for downtrodden black and hispanic yutes.
Okay... I've taken up enough of Happy's space.
Looking forward to your post on Sunday.
ReplyDeleteWhat frustrates me about the current system is that is just so hard to circumvent the system as a self-payer. You can't get appointments because people fear you won't ever pay, you get charged non-negotiated fees which are 10x what insurance companies pay, and you have to wait in long lines.
When my husband goes to the dermatologist in Italy, he pays $100 bucks under the table up front to be seen right away, and gets top notch care. It's fantastic. No mess, no fuss. If he wanted to skip the $100, he could wait 6 months, just like everyone else. The problem with our system now is that we're been too accommodating to those who scream that this is unfair.
Ye gods, what a bleak discussion. You all seem like an intelligent lot. Let me approach this socratically ...
ReplyDelete1) Do you generally agree with the thrust of the work by Wennberg et al on unwarranted variation in care?
2) Do you generally agree that there's a lot of fat in the private insurance infrastructure?
3) Are any of you familiar with the compression of morbidity hypothesis? Might it occur to you that you could actually depress the trajectory of utilization and spending of someone with multiple complex conditions in the grips of a frequent-flyer pattern and put them on a glide path so they are stabilized and then die peacefully in their sleep, at home? Could certain forms of home-based technologies play a role in this?
4) Is the problem not so much individual Americans and their behavior so much as a health care system that's overbuilt and overpaid? Hospitals that are giant black holes of cost creating demand to cover their enormous, self-created fixed costs? (See point on Wennberg above.) What if we could move a lot of care out of hospitals and other institutions and -- with the help of technology -- into homes and other community-based settings? If we can use technology to cut the cost of care by 25, 50, 90 percent, just by shifting the care setting, what does that do to this whole argument about rationing?
I don't disagree that at a certain point, folks have to be made to internalize the social costs of their behaviors. Am all for it. I find the conversation a little bewildering as it seems like rationing and the collapse of the MNB will be less the result of the consequences of those decisions (people in Europe smoke and drink a lot, last time I checked) than the collective behavior of the clinicians who are posting on this blog. It's like you're saying, keep paying us to engage in all of this lame behavior, and when you can't, we'll just need to ration care. In other words, maybe it's your behavior that needs to change as well? Could you be the change you want to see in the world? Or is that asking too much?
Ponder the questions above and call me in the morning.
-- Someone in Silicon Valley who clearly works in health care but isn't a clinician
I agree in principle, and, in fact, have argued many times on my blog that until we address rationing we'll never control costs of health care. The problem is -- and I don't see an answer here -- is what to do with those for whose care Medicare (for example) won't pay, and who have no resources. You said it's not about your willingness to care for them. So if you admit them, and care for them, and nobody pays, then what? Better, maybe, to bar the door and send them home? Pay to pick up the carcass?
ReplyDeleteI don't have the solution (well, I've proposed some) but I do think denying pay without barring the door ain't gonna fly.
Hey, if we are going to get all libertarian on ourselves, how about doing away with the legal monopoly that prevents market forces from determining the cost of care? It would probably be chaos, and snake oil salesmen galore, but we wouldn't have to pay $200 to go to a doctor to get a refill on a medication we've been on for years.
ReplyDeletePardon my (Canadian) ignorance, but don't the majority of Americans either get their health care through a HMO or Medicare already?
ReplyDeleteIf so, isn't that health care already essentially rationed?
Lifestyle rationing is not a fair way of doling out healthcare. Why is someone genetically predisposed to lung cancer more deserving of treatment then someone genetically or environmentally predisposed to smoking (parents smoked, nervous or social anxiety, oral fixation, etc). The answer is they are not.
ReplyDeleteAn HIV infected person most likely got infection by their lifestyle, but maybe they still deserve treatment. No?
Additionally, I may drink sometimes and smoke when doing so, but I also take exercise almost daily, get regular checkups and blood work, and eat a healthy vegetarian diet. Some good or bad lifestyle choices can not be followed or measured adequately, so its not fair to base it on them.
As is painfully obvious by the economy, risk assessment tools break down, so they shouldn't be used to gauge a persons medical options. The way to avert usage is to cover only certain treatments for everyone and have others be available for cash payment by patient. Thats it.