Where Should Treatment Decisions Get Made?

Our beloved little kitty, Maxie, left us on Friday. For those of you who have experienced the death of a pet, I am at the seeing ghosts stage of grieving.  With all the debate on end of life decisions and death panels dominating the news cycle these days,  in our case, the decision came down to this: the deteriorating physical condition and quality of life of the cat (terminal  cancer) outweighed the additional days or weeks of companionship. This decision was made by those who live with and loved the kitty. No veterinarian told us we had to do this, or when exactly to do it, though they described in a very helpful way what was happening, and prescribed medications that made the cat more comfortable.  Of course, the cat was not a participant in the ultimate decision, other than with the signals she was giving us as to her condition.   And in our case, no financial considerations were part of the decision.

Those who think that some right wing group is responsible for ginning up the concerns of older Americans about decisions about their future health care, and in particular end of life decisions  under the proposed health care reform bill, have not been reading or listening to  the continuous signals that have come out of the Administration.  The stimulus package, passed in February, allocated over a billion dollars for comparative effectiveness research.  What is the purpose of such studies, if not to provide a guide for physicians, and insurers?  

And how big a step is it from laying out the "best care plan" from implementing policies that require acceptance of it? How do you save money (bend the cost curve) if you don't change behavior patterns, and if patients and or their families or caregivers (physicians who think differently) can still ask for more care, and not the prescribed level of care in the recommended care plan?  

President Obama, in some of his rare unscripted moments, has continually railed against greedy doctors, and unnecessary tests and procedures, particularly for older Americans. The rest of the time he rails against insurance companies. It is not hard to see a plan here: a single payer who will rationally decide what is best for all, eliminating decision-making by greedy doctors (too much care) and greedy insurance companies (not enough care, and not enough patients insured). So, it is time for Goldilocks. As Obama has said on many occasions, it may not be just one step or piece of legislation that takes the country to this perceived higher state of affairs, but it is the way to go. And rationing will be part of it. Otherwise, there is not enough money to pay for those who already have coverage in the public insurance system (Medicare, Medicaid), not to mention the tens of millions more who will soon be added. 

There is plenty of waste in the Medicare system. Much of this is due to over-utilization of some procedures, and tests, which do not seem to add to survival, or improved outcomes.  Atul Gawande laid out the problem in a New Yorker article two months back. In some states, there is a lot of defensive medicine, particularly in the last year of a patient's life. Fear of lawsuits is the prime culprit here. But in some locations which Gawande explores, fear of malpractice litigation does not explain why one community in a state that has passed tort reform (McAllen, Texas), has double the cost for Medicare per patient as another in the same state (El Paso, Texas), when both communities have similar demographics and economic status. Something else is going on. A rational person might ask: how can Congress and the President even think of adding tens of millions of people into a new public health insurance program, given the enormous cost problems Gawande describes in the Medicare program, problems that have festered for decades, and led to increases in health care entitlement spending at near double the national inflation rate in recent years?

So the question is how do you eliminate waste, while providing the best care for patients?  The cookbook approach that will come out of comparative effectiveness surveys will inevitably lead to rationing -- whether along the lines of Britain or Canada or Oregon's rank order list of approved procedures for Medicaid. And it will also lead to a decline in innovation -- the new drugs, the new procedures, and the new technologies that are a big part of American medicine.

You do not have to be a fan of the TV program House to accept that some of the best doctors think outside the box. I recommend the books by Dr. Gawande and those by Dr. Jerome Groopman ("How Doctors Think") both of whom relate stories that prove the case.  You don't put in all those years in medical training to have your best judgment removed from the equation. Gawande is convinced that in some places in America, better care is delivered at lower cost, due to collaborative models of physician and provider behavior.  He makes no argument, however, that the better care that comes out of these local systems can be reduced to some list of treatment plans that all MDs should or could follow. In fact, his argument is for decentralized decision making attuned to the individual patient and his or her care plan. Gawande does not see any path to that model in any of the bills now being considered. 

What I see is a giant new tangled mess of bureaucratic constraints, and rules, that will not make the delivery system any better or more user friendly. America's health care future is being written by lawyers and bureaucrats and politicians and lobbyists, not medical professionals seeing patients. As Steve Chapman argues in the Chicago Tribune, Obama and his allies are proposing way too big a hammer to address the nail representing what is wrong with American health care. The great majority of Americans are happy with their health care. Despite the propaganda, there are not 46 million uninsured Americans who cannot obtain health care or insurance.  If you are here illegally, that might explain why you don't have health insurance (nearly 10 million of the 46 million).  If you earn over $75,000 a year, and have no insurance (10 million of the 46 million), it isn't, except in very rare cases, because you cannot afford to buy a policy. You have made a choice on how to spend your money, and in essence, have chosen to self-insure .  If you qualify for Medicaid or some other government program and don't sign up (another roughly 4.5 million, if not more), whose fault is that? Another 6.5 million of the so-called uninsured are actually insured by Medicaid or S-Chip, but the census taker does not know it. Sally Pipes argues that the number of "uninsured" who would qualify for existing programs is much higher -- as many as 14 million people.

For all the knocks on how the US fares versus other countries on comparative health measures, the real area where the US stands out is for a high number of murders and vehicular deaths, compared to other developed countries. Except for these two populations, where mortality has nothing to do with insurance coverage or the financing of health care, the US ranks number one in life expectancy. In some areas, such as cancer care, the US survival rate, is far ahead of other nations for most types of cancers.

The big problem with health care in America is high cost, and inflation, not limited access. The big problem with Medicare is over-utilization. The big problem with private insurance is much higher cost per procedure or test paid to physicians and hospitals (to subsidize providers for the far lower below cost fees paid by Medicare/Medicaid and the absence of payment by others -- charity care and bad debts).  That is a big part of why private insurance policies cost so much. Medicare squeezes on price per unit, since it does a poor job of controlling utilization, the number of units for which it pays. If Medicare did a better job on utilization control, and paid modestly higher fees, it might have lower total costs, and private insurance rates might drop since providers would not need as much of a subsidy.

If patients had higher deductibles and co-pays and were more personally conscious of the economic impact of the care they used, it might lead to more competition for the health care dollar, which would also help with the cost problem. There are problems with access in the individual insurance market, but this  issue can be addressed without any mega reform bill; allow insurance companies to sell across state lines and eliminate all the mandates for services that have to be covered, which drive up the price of health insurance everywhere. With bigger risk pools, insurance companies have committed to relaxing the internal rules on whom they insure. Health Savings Account  policies allow individuals to decide if they want to pay for acupuncture, or chiropractic care with their health care dollars.  Now lobbyists get states to add new mandated covered services each year. 

A majority (54%) of Americans would rather have no health care bill passed this year than any of the bills working their way through Congress.  Only a third (35%) like what they see developing. And this last number, not surprisingly, keeps dropping.  The Congress and the President would be well advised to follow the advice of the people on this, and start over.  There are rational ways to address what is wrong with health care in America, without damaging that which works well.  Now we have a reform bill that is primarily about politics, not quality of care, or access, or cost.  We can do better.

Richard Baehr is chief political correspondent of American Thinker.
Our beloved little kitty, Maxie, left us on Friday. For those of you who have experienced the death of a pet, I am at the seeing ghosts stage of grieving.  With all the debate on end of life decisions and death panels dominating the news cycle these days,  in our case, the decision came down to this: the deteriorating physical condition and quality of life of the cat (terminal  cancer) outweighed the additional days or weeks of companionship. This decision was made by those who live with and loved the kitty. No veterinarian told us we had to do this, or when exactly to do it, though they described in a very helpful way what was happening, and prescribed medications that made the cat more comfortable.  Of course, the cat was not a participant in the ultimate decision, other than with the signals she was giving us as to her condition.   And in our case, no financial considerations were part of the decision.

Those who think that some right wing group is responsible for ginning up the concerns of older Americans about decisions about their future health care, and in particular end of life decisions  under the proposed health care reform bill, have not been reading or listening to  the continuous signals that have come out of the Administration.  The stimulus package, passed in February, allocated over a billion dollars for comparative effectiveness research.  What is the purpose of such studies, if not to provide a guide for physicians, and insurers?  

And how big a step is it from laying out the "best care plan" from implementing policies that require acceptance of it? How do you save money (bend the cost curve) if you don't change behavior patterns, and if patients and or their families or caregivers (physicians who think differently) can still ask for more care, and not the prescribed level of care in the recommended care plan?  

President Obama, in some of his rare unscripted moments, has continually railed against greedy doctors, and unnecessary tests and procedures, particularly for older Americans. The rest of the time he rails against insurance companies. It is not hard to see a plan here: a single payer who will rationally decide what is best for all, eliminating decision-making by greedy doctors (too much care) and greedy insurance companies (not enough care, and not enough patients insured). So, it is time for Goldilocks. As Obama has said on many occasions, it may not be just one step or piece of legislation that takes the country to this perceived higher state of affairs, but it is the way to go. And rationing will be part of it. Otherwise, there is not enough money to pay for those who already have coverage in the public insurance system (Medicare, Medicaid), not to mention the tens of millions more who will soon be added. 

There is plenty of waste in the Medicare system. Much of this is due to over-utilization of some procedures, and tests, which do not seem to add to survival, or improved outcomes.  Atul Gawande laid out the problem in a New Yorker article two months back. In some states, there is a lot of defensive medicine, particularly in the last year of a patient's life. Fear of lawsuits is the prime culprit here. But in some locations which Gawande explores, fear of malpractice litigation does not explain why one community in a state that has passed tort reform (McAllen, Texas), has double the cost for Medicare per patient as another in the same state (El Paso, Texas), when both communities have similar demographics and economic status. Something else is going on. A rational person might ask: how can Congress and the President even think of adding tens of millions of people into a new public health insurance program, given the enormous cost problems Gawande describes in the Medicare program, problems that have festered for decades, and led to increases in health care entitlement spending at near double the national inflation rate in recent years?

So the question is how do you eliminate waste, while providing the best care for patients?  The cookbook approach that will come out of comparative effectiveness surveys will inevitably lead to rationing -- whether along the lines of Britain or Canada or Oregon's rank order list of approved procedures for Medicaid. And it will also lead to a decline in innovation -- the new drugs, the new procedures, and the new technologies that are a big part of American medicine.

You do not have to be a fan of the TV program House to accept that some of the best doctors think outside the box. I recommend the books by Dr. Gawande and those by Dr. Jerome Groopman ("How Doctors Think") both of whom relate stories that prove the case.  You don't put in all those years in medical training to have your best judgment removed from the equation. Gawande is convinced that in some places in America, better care is delivered at lower cost, due to collaborative models of physician and provider behavior.  He makes no argument, however, that the better care that comes out of these local systems can be reduced to some list of treatment plans that all MDs should or could follow. In fact, his argument is for decentralized decision making attuned to the individual patient and his or her care plan. Gawande does not see any path to that model in any of the bills now being considered. 

What I see is a giant new tangled mess of bureaucratic constraints, and rules, that will not make the delivery system any better or more user friendly. America's health care future is being written by lawyers and bureaucrats and politicians and lobbyists, not medical professionals seeing patients. As Steve Chapman argues in the Chicago Tribune, Obama and his allies are proposing way too big a hammer to address the nail representing what is wrong with American health care. The great majority of Americans are happy with their health care. Despite the propaganda, there are not 46 million uninsured Americans who cannot obtain health care or insurance.  If you are here illegally, that might explain why you don't have health insurance (nearly 10 million of the 46 million).  If you earn over $75,000 a year, and have no insurance (10 million of the 46 million), it isn't, except in very rare cases, because you cannot afford to buy a policy. You have made a choice on how to spend your money, and in essence, have chosen to self-insure .  If you qualify for Medicaid or some other government program and don't sign up (another roughly 4.5 million, if not more), whose fault is that? Another 6.5 million of the so-called uninsured are actually insured by Medicaid or S-Chip, but the census taker does not know it. Sally Pipes argues that the number of "uninsured" who would qualify for existing programs is much higher -- as many as 14 million people.

For all the knocks on how the US fares versus other countries on comparative health measures, the real area where the US stands out is for a high number of murders and vehicular deaths, compared to other developed countries. Except for these two populations, where mortality has nothing to do with insurance coverage or the financing of health care, the US ranks number one in life expectancy. In some areas, such as cancer care, the US survival rate, is far ahead of other nations for most types of cancers.

The big problem with health care in America is high cost, and inflation, not limited access. The big problem with Medicare is over-utilization. The big problem with private insurance is much higher cost per procedure or test paid to physicians and hospitals (to subsidize providers for the far lower below cost fees paid by Medicare/Medicaid and the absence of payment by others -- charity care and bad debts).  That is a big part of why private insurance policies cost so much. Medicare squeezes on price per unit, since it does a poor job of controlling utilization, the number of units for which it pays. If Medicare did a better job on utilization control, and paid modestly higher fees, it might have lower total costs, and private insurance rates might drop since providers would not need as much of a subsidy.

If patients had higher deductibles and co-pays and were more personally conscious of the economic impact of the care they used, it might lead to more competition for the health care dollar, which would also help with the cost problem. There are problems with access in the individual insurance market, but this  issue can be addressed without any mega reform bill; allow insurance companies to sell across state lines and eliminate all the mandates for services that have to be covered, which drive up the price of health insurance everywhere. With bigger risk pools, insurance companies have committed to relaxing the internal rules on whom they insure. Health Savings Account  policies allow individuals to decide if they want to pay for acupuncture, or chiropractic care with their health care dollars.  Now lobbyists get states to add new mandated covered services each year. 

A majority (54%) of Americans would rather have no health care bill passed this year than any of the bills working their way through Congress.  Only a third (35%) like what they see developing. And this last number, not surprisingly, keeps dropping.  The Congress and the President would be well advised to follow the advice of the people on this, and start over.  There are rational ways to address what is wrong with health care in America, without damaging that which works well.  Now we have a reform bill that is primarily about politics, not quality of care, or access, or cost.  We can do better.

Richard Baehr is chief political correspondent of American Thinker.