Rationing

I met a urologist from another city recently.  Since it had been a much discussed issue recently, I asked him what he thought about PSA testing. His answer was immediate.
\”I think PSA testing has been proven to save lives, and I have no doubt it should be done routinely.\”

When I mentioned the recent recommendation that prostate cancer screening be stopped after a man reaches 70, his faced turned red.  \”That report is clearly an attempt by the liberal media to set the stage for rationing of healthcare.  It was a flawed study and should not be taken as the final say on the matter.\”  He went on to recount cases of otherwise healthy 80 year-old men who developed high-grade prostate cancer, suffered, and died.

I chose not to debate him on the subject, but did point out that his view was that of one who sees the worst of the worst.  I personally can recall less than ten patients who died of prostate cancer in the fifteen years I have practiced.  My view is one that sees a non-diseased general public, and not worst-case scenarios.  I also didn\’t point out that even the American Cancer Society stopped pushing the test and states, and does not think as highly of the evidence as he does: \”Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives.\” (1).

But I digress.  What really struck me in the discussion was the way he pulled out the idea of rationing as the end-all hell for American healthcare.  It is regularly used as a scare tactic for those who advocate a \”free market approach\” to healthcare.  They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis.  Rationing healthcare seems a universal evil, and any step that is made toward cotroling cost is felt by some to be a push of the agenda of the Obama administration toward universal health coverage and ultimately rationing.

So what exactly is so bad about rationing?  The word itself refers to an individual being given a set amount of a limited resource, above which none will be available.  In healthcare, the idea is that each American is given only a set amount of coverage for care and above that they are left to fend for themselves.  Those who are either go over their limit or are felt to have a less legitimate claim on a scarce resource will be denied it.  This is especially scary for those who are the high-utilizers (the uninsurable that I have discussed previously), as they will use up their ration cards much faster than others.  I certainly understand this fear.

But are all limitations put on care really a step toward rationing?  Are limits put on care a bad thing?  The answer to that is simple:  DUH!  Of course not!  Of course there need to be limits on care!  Without control over what is paid for, the system will fall apart.  Here\’s why:

  1. Limited Resources – Not only are our resources limited, they need shrinking.  The overall cost of our system is very high and has to be controlled somehow.  Different interests are competing for resources, and by definition whoever doesn\’t win, doesn\’t get paid.  This means that someone needs to prioritize what is a necessity and what is not.
  2. Lack of personal culpability by patients – with both privately and publicly funded insurance, the actual cost to the patient is defrayed.  They are not harmed by unnecessary spending, so they don\’t try to control it.  Only uninsured patients are painfully aware of the cost of unnecessry tests.
  3. Lack of personal culpability by doctors – If I order an unnecessary test or expensive drug, I am not harmed by the waste.  For example, it is common practice by emergency physicians in our area to get a chest x-ray on children with fever.  Most of this is related to defensive medicine which is understandable in the ER, but clinically the test is often not warranted.  Yet the emergency physicians are not really affected by this waste, and the hospital and radiologists are actually rewarded by it if the insurance company pays for it (which they do).
  4. Incentives for other parties – As I just said, hospitals and radiologists have incentives to have wasteful procedures done.  The urologist I spoke to has a huge financial stake in the continuation of PSA testing, as it generates enormous business for him.  Drug companies want us to order their more expensive drugs than the generic alternatives.  This doesn\’t mean any of them are wrong, but they sure as heck won\’t fight waste if it harms them financially to do so.

When I was a physician starting out, the insurance companies would pay for pretty much any drug I prescribed.  At that time there were very expensive branded anti-inflamatory drugs that were aggressively pushed by the drug companies.  When the first drug formulary came around, the first thing that happened was that they forced me to use generic drugs of this type.  Before, there was no reason not to prescribe a brand, I had samples, and they were a tiny bit more convenient.  But when I changed there was really no negative effect on my patients.

One of our local hospitals just built a huge new cardiac center.  Statistically, our area is a very high-consumer of coronary artery stents compared to the national average.  Yet there are many cases in which an asymptomatic person will get a stent placed simply because they have abnormalities on their cardiac catheterization.  Logically this may make sense, but the data do not suggest that these people are helped at all.  Do you think that the hospital wants these procedures halted?  Do you think the cardiologists do?  Yet if they are truly unnecessary, shouldn\’t they be stopped?  Couldn\’t the $200 million they spent on their state-of-the-art facility be used in better ways?  Someone has to be looking at this and making sure the money spent is not wasted.

Without cost control a business will fail, and the same goes for our system.  Yet any suggestion at the elimination of clinically questionable procedures is met with cries of rationing.  Right now we are not at the point of rationing, and the act of trying to control cost by eliminating unnecessary procedures does not necessarily imply that the end goal is rationing.  The end goal is to spend money on necessary procedures instead of waste.  I sincerely doubt there is a left-wing conspiracy to push us to deny care where it is needed.  I doubt that the American Cancer Society is in favor of rationing.

Let\’s just spend our money wisely.  It\’s just common sense; not an evil plot.

28 thoughts on “Rationing”

  1. They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis.
    As an aside – I’ve lived in Canada all my life and had quite a bit of direct and indirect personal contact with the health care system (an extremely premature son, numerous gravely ill and critically injured relatives, relatives and friends who are health care professionals, etc) in two different provinces and I can honestly say that I’ve never heard of something like that happening here.

    I’m not saying it never happens, but I doubt it happens nearly as often as the right-wing “OMG universal health care!” alarmist propaganda would have Americans believe. In fact, everything I’ve read (including this blog, from the beginning) and heard from American friends about the US health care system suggests that health care access is as good or better in Canada.

    In fact, I’ve heard of far, far more care denial situations coming from the US. And no, not just from Michael Moore and the so-called “liberal media”.

    This is certainly not a well-researched statement backed up with citations and scientific evidence. But something to think about, perhaps, when claims are made that universal health care would be such a horrible thing for Americans?

    1. Point well taken. It’s definitely easier to get a coronary stent or an MRI scan in the US. As I said in this post, that may be a bad thing rather than a good one. Americans are afraid of being denied the right to get whatever they want (at least some of them are) and see denying any care as an infringement. Obviously I disagree.
      I would really want to hear what a Canadian with chronic health problems thinks about how their care compares with the Americans in the same situation.

  2. They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis.
    As an aside – I’ve lived in Canada all my life and had quite a bit of direct and indirect personal contact with the health care system (an extremely premature son, numerous gravely ill and critically injured relatives, relatives and friends who are health care professionals, etc) in two different provinces and I can honestly say that I’ve never heard of something like that happening here.

    I’m not saying it never happens, but I doubt it happens nearly as often as the right-wing “OMG universal health care!” alarmist propaganda would have Americans believe. In fact, everything I’ve read (including this blog, from the beginning) and heard from American friends about the US health care system suggests that health care access is as good or better in Canada.

    In fact, I’ve heard of far, far more care denial situations coming from the US. And no, not just from Michael Moore and the so-called “liberal media”.

    This is certainly not a well-researched statement backed up with citations and scientific evidence. But something to think about, perhaps, when claims are made that universal health care would be such a horrible thing for Americans?

    1. Point well taken. It’s definitely easier to get a coronary stent or an MRI scan in the US. As I said in this post, that may be a bad thing rather than a good one. Americans are afraid of being denied the right to get whatever they want (at least some of them are) and see denying any care as an infringement. Obviously I disagree.
      I would really want to hear what a Canadian with chronic health problems thinks about how their care compares with the Americans in the same situation.

  3. I think many fear that rationing means all or nothing, and that choice will be limited. Your bring up drug formularies and point out that , prior to drug formularies, we physicians had no incentive to use generic medications (other than common sense). However, insurance companies do not limit formularies to just generics. Most have a tiered system, usually with three tiers: generics ($10), preferred ($20), non-preferred ($45), as well as non-formulary. Physicians must now make decisions with their patients regarding whether or not the cost of the more expensive medications are worth it. Patients with more money clearly have an easier time making these choices. However, all patients with coverage have access to something. The public has come to accept this form of rationing. I wonder if this concept could not be applied to other areas of health care? In your scenairos above, colon cancer screening might be a tier 1 test (minimal cost to patients) since it has been shown to be both effective and cost effecitve; however, prostate cancer screening might cost patients more. The parents of the child in the ER could decide to wait on the X-ray since the physician didn’t think it was needed AND it was going to cost them more. Of course, the malpractice system would have to change for this to work, but the the concept of tiered health care similar to drug formularies which most are familiar with may be more palatable to the rationing phobics.

    1. Another option is to allow balance billing. If Medicare had a fixed contribution to various procedures and docs/hospitals could bill the difference, then we could set our fees ahead of time and give patients way more information about the real cost of things. It makes a whole lot more sense to me than the way Medicare does it.
      I have never thought about the tiered system. People will resist it big-time, as they have accused the comparative efficacy studies as being a front for future rationing.

  4. I think many fear that rationing means all or nothing, and that choice will be limited. Your bring up drug formularies and point out that , prior to drug formularies, we physicians had no incentive to use generic medications (other than common sense). However, insurance companies do not limit formularies to just generics. Most have a tiered system, usually with three tiers: generics ($10), preferred ($20), non-preferred ($45), as well as non-formulary. Physicians must now make decisions with their patients regarding whether or not the cost of the more expensive medications are worth it. Patients with more money clearly have an easier time making these choices. However, all patients with coverage have access to something. The public has come to accept this form of rationing. I wonder if this concept could not be applied to other areas of health care? In your scenairos above, colon cancer screening might be a tier 1 test (minimal cost to patients) since it has been shown to be both effective and cost effecitve; however, prostate cancer screening might cost patients more. The parents of the child in the ER could decide to wait on the X-ray since the physician didn’t think it was needed AND it was going to cost them more. Of course, the malpractice system would have to change for this to work, but the the concept of tiered health care similar to drug formularies which most are familiar with may be more palatable to the rationing phobics.

    1. Another option is to allow balance billing. If Medicare had a fixed contribution to various procedures and docs/hospitals could bill the difference, then we could set our fees ahead of time and give patients way more information about the real cost of things. It makes a whole lot more sense to me than the way Medicare does it.
      I have never thought about the tiered system. People will resist it big-time, as they have accused the comparative efficacy studies as being a front for future rationing.

  5. British view.
    Yes, we have a situation where not everyone who is referred to a specialist gets seen as soon as might be desirable, but I’m not sure that this is rationing as such. Our waiting lists for specialist appointments following a referal are frequently affected by the availability of clinic time with the relevant specialty in the relevant Health Board area. To illustrate with an example which most people will be familiar with the geography (I’m using New York boroughs for illustrative purposes) of, a PHP in Queens Health Board would normally be expected to refer their list to a specialist in Queens, even when there were underemployed specialists in the Bronx Health Board area. The reason I’m not sure this is rationing is that, continuing the example, Queens might be short of cardiologists, but have spare pediatrians, whilst the reverse happens to be true for the Bronx.

  6. British view.
    Yes, we have a situation where not everyone who is referred to a specialist gets seen as soon as might be desirable, but I’m not sure that this is rationing as such. Our waiting lists for specialist appointments following a referal are frequently affected by the availability of clinic time with the relevant specialty in the relevant Health Board area. To illustrate with an example which most people will be familiar with the geography (I’m using New York boroughs for illustrative purposes) of, a PHP in Queens Health Board would normally be expected to refer their list to a specialist in Queens, even when there were underemployed specialists in the Bronx Health Board area. The reason I’m not sure this is rationing is that, continuing the example, Queens might be short of cardiologists, but have spare pediatrians, whilst the reverse happens to be true for the Bronx.

  7. Hi Rob- I don’t pretend for a second to be knowledgeable regarding our health care system other then what I have gleaned from reading in the med blogasphere over the last 2 years. And I am writing from a patient’s perspective.
    I think there has to be responsibility with all parties concerned.

    I have read comments from people in other countries regarding their health care. Some have no complaints and some do. I think it was someone from Greece who discussed that they don’t use heroic measures on anyone that would be considered to have a lesser quality of life (not their words verbatim) and certainly not the elderly population.

    I know that many medical people would agree that we waste money keeping people alive that have so many co-morbidities that they are incapable of living a quality life. Millions spent on one patient to keep them alive on a vent, expensive treatments, etc., when they would’ve died of natural causes.

    I found myself (knowing full well the value of a DNR/advanced directives), floundering intellectually in the ED the night my mother died. Perhaps selfish, but I was grateful the advanced directives never got turned in and I was grateful the nursing home staff never requested the DNR my mother previously filled out 2 years earlier from the doctor’s office and I was grateful they couldn’t reach her doctor…because it gave me a few more hours with her. Otherwise they wouldn’t have intubated her and she would’ve died at the nursing home.

    Here’s the thing… while an unexpected GI bleed lead to her death… the quality of her life had diminished greatly over the previous 6 months. An exacerbating dementia, she became frail, was unable to care for herself in any way other than feed herself which was also becoming a challenge and she couldn’t ambulate or even support her own weight… or read…she was an avid reader, and other things. She basically was at the mercy of the staff for putting on music, changing a channel and I often found her just sitting in her wheel chair… not even able to prop her self back up if she slid down, etc. Her *quality* of life that she had known for 85 yrs and 3 months was no longer there.

    I *saw* all this… and yet that night in the ED…I did not want to let her go. The ED Doc did inquire what I wanted to do, which surprised me since they didn’t have advanced directives. I wanted them to do what they could…all the while knowing I was wrong to say that.

    I finally went out to the doctor and said.. I can’t see the forest for the trees with this right now and I need to speak with someone. I said they needed to speak with her doctor but they still couldn’t get him. So I said..”I’m her daughter. I just can’t say what I know I am supposed to say.”

    A few minutes later the hospitalist brought me to “the room” no one wants to go to when a loved one is in the ED, we talked and had a plan. Which was not to do anything that would prolong suffering.

    Fortunately for Mom, she died about 10 minutes after going back into her room.

    I said all that to say…. how many people are telling medical staff to keep family members alive that if they could speak for themselves…would not want to. And how much money does this care cost our system annually?

    So if rationing Would offset that type of senseless care… then I would say it is a good thing. I use the rationing word because other bloggers from other countries that have universal health care have stated that the government does not allow for these things because there is not enough money to do so.

    I have also read from bloggers, (not right wing media) that people do die because there are waiting lists to get in for routine procedures, but the cancer is not caught in time. Or more recently on the news… In England (I think) they won’t approve of a Cancer drug that they know can save lives because it is too expensive.

    One woman told me she would not want to have breast CA in the UK.
    Those stories scare me. Again… I have read these things over the last 2 years in the medblogs, via physicians, other med professionals and commentators-professionals and patients.

    One Canadian woman did tell me she didn’t have any complaints about their health care system… but she said quality of care may also depend on which province you live in which may determine funding, thus availability of care and quality/availability of facilities and equipment.

    I know in Michael Moore’s film..he showed people getting better care in Cuba (not even going there) and the American woman receiving better care in Canada… but people come from all over the world to seek medical treatment in this country. And I have often (even Reader’s digest years ago) read of Canadians coming down here to get surgeries, etc., so they wouldn’t have to wait.

    The only reason I’d want universal is that having balances to med bills ads up when you have a lot of tests, procedures and hospital stays or God forbid..something catastrophic. I like that no one’s credit would be ruined or they won’t lose their house.

    ***However, I am concerned about the quality and availability of health care being compromised and the intrusion of government… possibly dictating how care should go based on financial feasibility vs risk, outcomes, med history, etc.

    If we think insurance companies are shrewd, disingenuous and obtrusive… just imagine the government’s red tape. Or..Would it be better-more fair?

    I have been very healthy most of my life, and am now… but over recent years became a patient who has been reliant on multiple urology procedures and patient testing. When you are younger and healthy… none of this matters. But now…when I read all these things and hear the news… I feel uneasy.

    The baby boomer population is aging. Thus will be increasingly more of a burden on the health care system.

    Rob… you are so right about cost and lack of personal culpability by patients and doctors. (Throckmorton’s Other Signs blog has a post up now: http://throckmortonsothersigns.blogspot.com/2009/05/its-not-my-money-test.html discussing how patients opt to do things because they don’t have to pay for it. You see it in the ER’s. I have heard and I don’t know if it is true…that the reason the insurance companies have the regulations they do now is because up until the early 90s…doctors were padding the bills and ordering everything. There weren’t any controls.

    I also feel badly for people who don’t have insurance. But for anyone who thinks health care will be “Free”… it will cost us in other ways… there’s always a trade off and as a patient…I am afraid it could be rationing, lack of available doctors, equipment or open schedules for procedures, surgeries and tests, etc.

    I think under a universal system… it will be wonderful if the uninsured male patient presenting to the ED with chest pain will allow himself to be admitted overnight for observation vs signing out AMA because he is afraid of incurring a huge hospital bill. That would be a good thing.

    But I am seriously concerned about having some government agency filled with reps making the decisions, who do not have the medical expertise to decide correctly which medical care/treatments I or loved ones should have.

    I go to my doctor… because *he* does have the education/expertise and knows me and *is* the more reliable person to dictate my medical care.

    And last but not least… while I do know there is waste and our country does spend a lot to keep people alive that maybe should be allowed to die… I also fear that someone could be crunching numbers somewhere and based on those numbers decide a patient isn’t *worth* saving…when maybe they could be saved and would go on to live a healthy and productive life.

    Where does it end or what could these cost effective decision making processes snowball down to?

    And with med records eventually going all electronic… how secure will our personal medical histories be… and is it possible that patients could ever be categorized into care levels/medications allowed based on said medical histories?

    How often do we here how hospital staff/patients are adversely affected because some administrative pencil pusher (their job IS important too), gets over zealous with budget cuts… making these decisions without knowing first hand what actually goes on in the trenches?

    Lawsuits. It seems our litigious society also has culpability in driving up the cost of medicine. How much money is spent in defensive medicine?

    I don’t know anything about this other than I have heard that Canada doesn’t have the problems with frivolous medical lawsuits and if that is true… perhaps we should learn from them.

    Our medical system is failing and something has to be done… but I do feel uneasy/wary of who and by what criteria worthiness of medical care… the expensive *life saving* care will be decided.

    And.. by all means..we should always look for ways to be cost effective but without compromising quality of care.

    Last fall Charity Doc shared his insights on how to fix the system: http://fingersandtubesineveryorifice.blogspot.com/2008/10/fixing-our-broken-health-care-system.html

    I just hope that this administration will be seriously consulting with medical professionals who because of their experience/professional expertise will accurately represent the needs of our health care system and consequences of decisions being made. I hope that quality with availability and profound respect for human life of all ages… won’t be sacrificed for some Utopian ideology that looks good on paper, but proves to be the catalyst for an even more compromised medical system.

    I think that the blogging docs should get their voices heard before final decisions are made. You all have so many good insights… because this IS what you do every day.

    1. {Seaspray}About 6 years ago I was in a similar position, but with my Dad, and my Mum being legal next of kin (which is as well, because other than by fortunate timing I couldn’t get to where they lived in less than a day).

      So on Monday I got a call to say that he’d been admitted with pneumonia, and made plans to go and visit the following weekend. On Tuesday evening I got another call to say that his DNR and “no heroic measures” had cut in and he’d died peacefully a couple of hours earlier, So I never did get those last few hours with him 🙁 but equally I know he wasn’t more or less tortured just to give me those hours, and on balance I view that as a win.

  8. Hi Rob- I don’t pretend for a second to be knowledgeable regarding our health care system other then what I have gleaned from reading in the med blogasphere over the last 2 years. And I am writing from a patient’s perspective.
    I think there has to be responsibility with all parties concerned.

    I have read comments from people in other countries regarding their health care. Some have no complaints and some do. I think it was someone from Greece who discussed that they don’t use heroic measures on anyone that would be considered to have a lesser quality of life (not their words verbatim) and certainly not the elderly population.

    I know that many medical people would agree that we waste money keeping people alive that have so many co-morbidities that they are incapable of living a quality life. Millions spent on one patient to keep them alive on a vent, expensive treatments, etc., when they would’ve died of natural causes.

    I found myself (knowing full well the value of a DNR/advanced directives), floundering intellectually in the ED the night my mother died. Perhaps selfish, but I was grateful the advanced directives never got turned in and I was grateful the nursing home staff never requested the DNR my mother previously filled out 2 years earlier from the doctor’s office and I was grateful they couldn’t reach her doctor…because it gave me a few more hours with her. Otherwise they wouldn’t have intubated her and she would’ve died at the nursing home.

    Here’s the thing… while an unexpected GI bleed lead to her death… the quality of her life had diminished greatly over the previous 6 months. An exacerbating dementia, she became frail, was unable to care for herself in any way other than feed herself which was also becoming a challenge and she couldn’t ambulate or even support her own weight… or read…she was an avid reader, and other things. She basically was at the mercy of the staff for putting on music, changing a channel and I often found her just sitting in her wheel chair… not even able to prop her self back up if she slid down, etc. Her *quality* of life that she had known for 85 yrs and 3 months was no longer there.

    I *saw* all this… and yet that night in the ED…I did not want to let her go. The ED Doc did inquire what I wanted to do, which surprised me since they didn’t have advanced directives. I wanted them to do what they could…all the while knowing I was wrong to say that.

    I finally went out to the doctor and said.. I can’t see the forest for the trees with this right now and I need to speak with someone. I said they needed to speak with her doctor but they still couldn’t get him. So I said..”I’m her daughter. I just can’t say what I know I am supposed to say.”

    A few minutes later the hospitalist brought me to “the room” no one wants to go to when a loved one is in the ED, we talked and had a plan. Which was not to do anything that would prolong suffering.

    Fortunately for Mom, she died about 10 minutes after going back into her room.

    I said all that to say…. how many people are telling medical staff to keep family members alive that if they could speak for themselves…would not want to. And how much money does this care cost our system annually?

    So if rationing Would offset that type of senseless care… then I would say it is a good thing. I use the rationing word because other bloggers from other countries that have universal health care have stated that the government does not allow for these things because there is not enough money to do so.

    I have also read from bloggers, (not right wing media) that people do die because there are waiting lists to get in for routine procedures, but the cancer is not caught in time. Or more recently on the news… In England (I think) they won’t approve of a Cancer drug that they know can save lives because it is too expensive.

    One woman told me she would not want to have breast CA in the UK.
    Those stories scare me. Again… I have read these things over the last 2 years in the medblogs, via physicians, other med professionals and commentators-professionals and patients.

    One Canadian woman did tell me she didn’t have any complaints about their health care system… but she said quality of care may also depend on which province you live in which may determine funding, thus availability of care and quality/availability of facilities and equipment.

    I know in Michael Moore’s film..he showed people getting better care in Cuba (not even going there) and the American woman receiving better care in Canada… but people come from all over the world to seek medical treatment in this country. And I have often (even Reader’s digest years ago) read of Canadians coming down here to get surgeries, etc., so they wouldn’t have to wait.

    The only reason I’d want universal is that having balances to med bills ads up when you have a lot of tests, procedures and hospital stays or God forbid..something catastrophic. I like that no one’s credit would be ruined or they won’t lose their house.

    ***However, I am concerned about the quality and availability of health care being compromised and the intrusion of government… possibly dictating how care should go based on financial feasibility vs risk, outcomes, med history, etc.

    If we think insurance companies are shrewd, disingenuous and obtrusive… just imagine the government’s red tape. Or..Would it be better-more fair?

    I have been very healthy most of my life, and am now… but over recent years became a patient who has been reliant on multiple urology procedures and patient testing. When you are younger and healthy… none of this matters. But now…when I read all these things and hear the news… I feel uneasy.

    The baby boomer population is aging. Thus will be increasingly more of a burden on the health care system.

    Rob… you are so right about cost and lack of personal culpability by patients and doctors. (Throckmorton’s Other Signs blog has a post up now: http://throckmortonsothersigns.blogspot.com/2009/05/its-not-my-money-test.html discussing how patients opt to do things because they don’t have to pay for it. You see it in the ER’s. I have heard and I don’t know if it is true…that the reason the insurance companies have the regulations they do now is because up until the early 90s…doctors were padding the bills and ordering everything. There weren’t any controls.

    I also feel badly for people who don’t have insurance. But for anyone who thinks health care will be “Free”… it will cost us in other ways… there’s always a trade off and as a patient…I am afraid it could be rationing, lack of available doctors, equipment or open schedules for procedures, surgeries and tests, etc.

    I think under a universal system… it will be wonderful if the uninsured male patient presenting to the ED with chest pain will allow himself to be admitted overnight for observation vs signing out AMA because he is afraid of incurring a huge hospital bill. That would be a good thing.

    But I am seriously concerned about having some government agency filled with reps making the decisions, who do not have the medical expertise to decide correctly which medical care/treatments I or loved ones should have.

    I go to my doctor… because *he* does have the education/expertise and knows me and *is* the more reliable person to dictate my medical care.

    And last but not least… while I do know there is waste and our country does spend a lot to keep people alive that maybe should be allowed to die… I also fear that someone could be crunching numbers somewhere and based on those numbers decide a patient isn’t *worth* saving…when maybe they could be saved and would go on to live a healthy and productive life.

    Where does it end or what could these cost effective decision making processes snowball down to?

    And with med records eventually going all electronic… how secure will our personal medical histories be… and is it possible that patients could ever be categorized into care levels/medications allowed based on said medical histories?

    How often do we here how hospital staff/patients are adversely affected because some administrative pencil pusher (their job IS important too), gets over zealous with budget cuts… making these decisions without knowing first hand what actually goes on in the trenches?

    Lawsuits. It seems our litigious society also has culpability in driving up the cost of medicine. How much money is spent in defensive medicine?

    I don’t know anything about this other than I have heard that Canada doesn’t have the problems with frivolous medical lawsuits and if that is true… perhaps we should learn from them.

    Our medical system is failing and something has to be done… but I do feel uneasy/wary of who and by what criteria worthiness of medical care… the expensive *life saving* care will be decided.

    And.. by all means..we should always look for ways to be cost effective but without compromising quality of care.

    Last fall Charity Doc shared his insights on how to fix the system: http://fingersandtubesineveryorifice.blogspot.com/2008/10/fixing-our-broken-health-care-system.html

    I just hope that this administration will be seriously consulting with medical professionals who because of their experience/professional expertise will accurately represent the needs of our health care system and consequences of decisions being made. I hope that quality with availability and profound respect for human life of all ages… won’t be sacrificed for some Utopian ideology that looks good on paper, but proves to be the catalyst for an even more compromised medical system.

    I think that the blogging docs should get their voices heard before final decisions are made. You all have so many good insights… because this IS what you do every day.

    1. {Seaspray}About 6 years ago I was in a similar position, but with my Dad, and my Mum being legal next of kin (which is as well, because other than by fortunate timing I couldn’t get to where they lived in less than a day).

      So on Monday I got a call to say that he’d been admitted with pneumonia, and made plans to go and visit the following weekend. On Tuesday evening I got another call to say that his DNR and “no heroic measures” had cut in and he’d died peacefully a couple of hours earlier, So I never did get those last few hours with him 🙁 but equally I know he wasn’t more or less tortured just to give me those hours, and on balance I view that as a win.

  9. I am a high-utilizer and essentially uninsurable if it weren’t for employer group plans.
    If US healthcare evolves into ‘rationed’ healthcare similar to Canada/NHS, I personally wouldn’t mind it. I think in a way, that’d help make people a little more level-headed rather than think every little symptom was worthy of a new specialist/diagnostic testing because they know they can get it and have insurance pay for it.
    I believe our current healthcare system is allowing to a degree, proliferation in hypochondriac-ish behaviors in certain people with chronic health conditions. ( This of course is only my personal observation.)

    A woman I know who’s in Canada mentioned that if US healthcare is nationalized, we wouldn’t have the same long-wait problem her providence has because we have larger quantity of healthcare. Her providence has only a couple of MRI equipment, while a single county in, lets say northeast of US has out numbers that amount.

  10. I am a high-utilizer and essentially uninsurable if it weren’t for employer group plans.
    If US healthcare evolves into ‘rationed’ healthcare similar to Canada/NHS, I personally wouldn’t mind it. I think in a way, that’d help make people a little more level-headed rather than think every little symptom was worthy of a new specialist/diagnostic testing because they know they can get it and have insurance pay for it.
    I believe our current healthcare system is allowing to a degree, proliferation in hypochondriac-ish behaviors in certain people with chronic health conditions. ( This of course is only my personal observation.)

    A woman I know who’s in Canada mentioned that if US healthcare is nationalized, we wouldn’t have the same long-wait problem her providence has because we have larger quantity of healthcare. Her providence has only a couple of MRI equipment, while a single county in, lets say northeast of US has out numbers that amount.

  11. We already have rationing. It’s based on ability to pay, or to be insured, instead of on something more fair, such as “of proven scientific benefit.”

  12. We already have rationing. It’s based on ability to pay, or to be insured, instead of on something more fair, such as “of proven scientific benefit.”

  13. Doc. The issue isn’t republican or democrat. The issue is government. Whenever a government pays for something it must be funded by tax payers. If the government offers health care with no limits, the FREE=MORE mentality will bankrupt the treasury. We see witness to this with the 10 trillion dollar plus deficit of the Medicare National Bank.
    With out limits FREE=MORE cannot survive. And the government will never price services correctly. 300 million Americans will always price anything better than a handful of political junkies collecting handouts from the wallets of lobbyists.

    I can’t imagine any third party system that can fund itself without established overt rationing. We live in a medicalized society where more is always better. And that is not sustainable.

  14. Doc. The issue isn’t republican or democrat. The issue is government. Whenever a government pays for something it must be funded by tax payers. If the government offers health care with no limits, the FREE=MORE mentality will bankrupt the treasury. We see witness to this with the 10 trillion dollar plus deficit of the Medicare National Bank.
    With out limits FREE=MORE cannot survive. And the government will never price services correctly. 300 million Americans will always price anything better than a handful of political junkies collecting handouts from the wallets of lobbyists.

    I can’t imagine any third party system that can fund itself without established overt rationing. We live in a medicalized society where more is always better. And that is not sustainable.

  15. ken O -I’m sorry that happened with your Dad as I know the sadness and frustration behind that, but I am happy you have found solace in that he didn’t suffer. That IS a comforting thing to know.
    I have wondered if she did. ? But I think by the time she was out of it…i don’t think the intubation bothered her and they couldn’t even give her pain meds because her bp was so low. The ED doc, in an effort to help me feel better I guess, said”Look! She’s resting peacefully..she’d not agitated.” and it did help somewhat. I worry more how she felt the couple of days..maybe months prior. I think patients with dementia are passed over or blown off because they can’t articulate with *consistency* a specific problem..if at all. (There HAS to be a way around that! ??)

    As her daughter and knowing her reactions…I DO believe something was going on for a couple of months in her abdomen and I did try to call attention to it… evidently not insistent enough.

    However, if they had found something..in her frail condition..could she have tolerated interventions? I don’t know. Her quality of life wasn’t there either. But maybe she could’ve been made more comfortable. ? i guess..in the end…when it is your time…it is your time.
    *******************
    I think regarding hypochondriac-ish patients…that the physician is the one with the medical knowledge/expertise and should give their honest opinion. However, because of the *potential* for a lawsuit if they don’t order a test to rule something out… CYA takes over. I know..not always… but I read about this often in the medblogs and saw it when working with the ED.

    I don’t blame physicians for protecting themselves. BUT it is part of the problem. There will always be the patient who doesn’t listen to reason.. or because it’s “FREE”, but I for one..would not have had an abd CT in one instance if my doc had explained that there was more risk from the CT vs the incidental finding on a previous CT.

    I think if you tell patients they are at more risk for cancer from the radiation than they are from their injury/symptoms…they might think twice about said tests. Or can the physician then be sued for scaring the patient into not having the test?

    Lawsuits are out of control and definitely driving up costs in medicine… and possibly causing more patients to be subjected to unnecessary tests that could harm them in the future.

    I think that while the US may have an abundance of mRI-radiology equipment *NOW* vs what Canada may have in a providence… that equipment availability will diminish as funds diminish in a socialized health care program.

    Right now…medicine in this country reaps the benefits of a free enterprise heath care system…warts and all. We have abundance because the money isn’t *rationed* yet. Yes..our system is flawed and in trouble… but it is not the level of rationing that we may be facing… says this non-medically oriented patient. 🙂

  16. ken O -I’m sorry that happened with your Dad as I know the sadness and frustration behind that, but I am happy you have found solace in that he didn’t suffer. That IS a comforting thing to know.
    I have wondered if she did. ? But I think by the time she was out of it…i don’t think the intubation bothered her and they couldn’t even give her pain meds because her bp was so low. The ED doc, in an effort to help me feel better I guess, said”Look! She’s resting peacefully..she’d not agitated.” and it did help somewhat. I worry more how she felt the couple of days..maybe months prior. I think patients with dementia are passed over or blown off because they can’t articulate with *consistency* a specific problem..if at all. (There HAS to be a way around that! ??)

    As her daughter and knowing her reactions…I DO believe something was going on for a couple of months in her abdomen and I did try to call attention to it… evidently not insistent enough.

    However, if they had found something..in her frail condition..could she have tolerated interventions? I don’t know. Her quality of life wasn’t there either. But maybe she could’ve been made more comfortable. ? i guess..in the end…when it is your time…it is your time.
    *******************
    I think regarding hypochondriac-ish patients…that the physician is the one with the medical knowledge/expertise and should give their honest opinion. However, because of the *potential* for a lawsuit if they don’t order a test to rule something out… CYA takes over. I know..not always… but I read about this often in the medblogs and saw it when working with the ED.

    I don’t blame physicians for protecting themselves. BUT it is part of the problem. There will always be the patient who doesn’t listen to reason.. or because it’s “FREE”, but I for one..would not have had an abd CT in one instance if my doc had explained that there was more risk from the CT vs the incidental finding on a previous CT.

    I think if you tell patients they are at more risk for cancer from the radiation than they are from their injury/symptoms…they might think twice about said tests. Or can the physician then be sued for scaring the patient into not having the test?

    Lawsuits are out of control and definitely driving up costs in medicine… and possibly causing more patients to be subjected to unnecessary tests that could harm them in the future.

    I think that while the US may have an abundance of mRI-radiology equipment *NOW* vs what Canada may have in a providence… that equipment availability will diminish as funds diminish in a socialized health care program.

    Right now…medicine in this country reaps the benefits of a free enterprise heath care system…warts and all. We have abundance because the money isn’t *rationed* yet. Yes..our system is flawed and in trouble… but it is not the level of rationing that we may be facing… says this non-medically oriented patient. 🙂

  17. Hello Dr. Rob,I am a Family Physician, and judging about the timeframe you described in your piece, I am about your age.
    My 86 yo father is in an ICU in Miami; part of the reason that I am writing instead of sleeping. “He was in his usual state of excellent health” literally until the day he turned 86. So my family thinks. Since then, he has been hospitalized 5 times in 5 months. My family, all laypeople, think “the doctors haven’t gotten it right”. I knew absolutely, positively, on the day of his first admission, that his time on earth had come to an imminent end. But the doctors who are treating him keep finding new problems, which I anxiously get calls about. I have told them “with all due respect and love for Dad, the more they look, the more they will find that needs fixing”. I feel like the family’s Dr. K. I have insisted over and over that the most important thing is to stabilize him so that he can go home. Well, starting with my Dad, they want to let the doctors keep fixing things. You see, no one in my family has ever considered that he could die. I realize that what they are doing is buying time in which to come to accept the stark truth. But in the buying of time, millions of dollars are spent, and not wisely. I do NOT want my Dad to die. God knows, I have seen hundreds of patients who cost us more millions of dollars, and why should he be the first to be ‘rationed’?
    In conclusion, I think that one of the most cost-effective, and probably the least likely reform to be embraced, is to educate Americans about what to expect about extreme age and death, and how to prepare while one is young to deal with the certainty that one will die. Everyone else in the world accepts that dying at an advanced age, in a dignified manner, is a blessing, not a curse of short-comings in healthcare.

    1. You are right on. The unfortunate thing for your family is that the doctor should be doing that education. It seems like they have been lead to believe that more care is better than less. Of course, the public education you suggest will be called a left-wing plot to ration care. How dare us limit anything!

  18. Hello Dr. Rob,I am a Family Physician, and judging about the timeframe you described in your piece, I am about your age.
    My 86 yo father is in an ICU in Miami; part of the reason that I am writing instead of sleeping. “He was in his usual state of excellent health” literally until the day he turned 86. So my family thinks. Since then, he has been hospitalized 5 times in 5 months. My family, all laypeople, think “the doctors haven’t gotten it right”. I knew absolutely, positively, on the day of his first admission, that his time on earth had come to an imminent end. But the doctors who are treating him keep finding new problems, which I anxiously get calls about. I have told them “with all due respect and love for Dad, the more they look, the more they will find that needs fixing”. I feel like the family’s Dr. K. I have insisted over and over that the most important thing is to stabilize him so that he can go home. Well, starting with my Dad, they want to let the doctors keep fixing things. You see, no one in my family has ever considered that he could die. I realize that what they are doing is buying time in which to come to accept the stark truth. But in the buying of time, millions of dollars are spent, and not wisely. I do NOT want my Dad to die. God knows, I have seen hundreds of patients who cost us more millions of dollars, and why should he be the first to be ‘rationed’?
    In conclusion, I think that one of the most cost-effective, and probably the least likely reform to be embraced, is to educate Americans about what to expect about extreme age and death, and how to prepare while one is young to deal with the certainty that one will die. Everyone else in the world accepts that dying at an advanced age, in a dignified manner, is a blessing, not a curse of short-comings in healthcare.

    1. You are right on. The unfortunate thing for your family is that the doctor should be doing that education. It seems like they have been lead to believe that more care is better than less. Of course, the public education you suggest will be called a left-wing plot to ration care. How dare us limit anything!

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