Choose Your Poison!
Personal medicine or population medicine: which will it be for you?
Personal medicine starts with you and your doctor discussing what is the best care for you. After considering long-term medical effects as well as financial costs, you and your provider decide what to do.
Population medicine means that some panel, committee, or group determines what it consider cost-effective for a population. That could be an insurance company or a government agency. Medical care that is deemed "cost-effective" is authorized and therefore available for use.
Medical care adjudged not cost-effective for the population is...well, not: not authorized, not paid for, and therefore not available for use in patients (other than some who might be connected enough to get waivers). This is what is known as practicing medicine for the mean, the middle, or the system. Others call it rationing.
Population medicine is health care practiced by bureaucrats and administrators, ostensibly for the welfare of a population. By contrast, personal medicine is health care practiced by doctors and nurses for the welfare of individual persons.
You choose: personal medicine or population medicine. If you ignore this question, the choice will be made for you (in your best interest, of course).
Universal health care countries such as Canada, Great Britain, and New Zealand overtly practice population medicine. Each government claims that it knows best. The government decides what works and what does not. The former is approved, and the latter is unavailable. Father knows best and decides what is best for the mythical average patient.
However, as scientist Stephen Jay Gould personally proved by surviving "terminal" lung cancer for over twenty years, there is no "average" patient. What is best for the average patient in a large statistical population is often not best for any individual person.
Providers do not treat mythical patients. They treat real people, with names, families, and multiple responsibilities. In our culture, ethical standards for good health care require doing the best possible for each individual patient. In America, the patient knows best, not "Father" in the guise of government.
To see population medicine in action, check out the online article "If I lived in New Zealand, I'd be dead." The author reports that she had an unusual form of breast cancer for which approved therapies in New Zealand (where she lived) did not work. A new but expensive anti-cancer drug -- Herceptin -- had shown great promise. Though her doctor and she wanted that drug, it was not approved by the government and therefore was not authorized for payment. Fortunately, she had the money to pay out-of-pocket for the Herceptin, did so, and lived to tell her tale. Most people would not have the money and would simply have died.
The U.S. currently has the worst of both worlds. In the popular mind, there is personal medicine. However, the patient is disconnected from his or her money. There is also a strong incursion of population medicine, which the Obama administration's Affordable Care Act increases dramatically. Both insurance companies and government agencies -- i.e., Medicare and Medicaid -- authorize (pay for) what is cheapest for them, not what is best for the patient. The result is a constant struggle between provider and payer, with the patient caught in the middle, bouncing around like a pinball, with no ability to decide his own care.
(A friend and adviser suggested that I call population medicine what it effectively is: political medicine. I decided to stick with population medicine, as the focus here is considering the question of in whose best interest is the medicine being practiced, and only after that, who is practicing the medicine?)
The ACA -- the disingenuously titled Patient Protection and Affordable Health Care Act of 2010 -- establishes an independent agency called IPAB, or the Independent Payment Advisory Board. IPAB will review all expensive medical therapies and decide which are deemed cost-effective and which are not. "Not cost-effective" treatments would become unavailable for use by Medicare and Medicaid patients. Even if there is good reason to believe that one of those treatments is the best possible for you or your child, sorry, Charlie!
IPAB was modeled after another disingenuously titled British agency with the acronym NICE (National Institute for Clinical Excellence). Their population medicine-based "clinical excellence" produced age limits for certain treatments such as kidney dialysis (not cost-effective after age 55) and heart surgery (over age 65). These treatments are much more costly than Herceptin and beyond the financial reach of 99% of the population.
In Canada, even the 1% who might be rich enough to pay for such treatments cannot access them. Any attempt to use non-approved therapies, even if paid for by the patient, is severely punished.
Let's return to the question up top. Which do you want: personal medicine or population medicine? If you choose not to decide, or fail to make your choice very obvious to your representatives, you know what will happen.
Now you need to consider two related questions. 1) In population medicine, is there any personal responsibility for a patient to protect his or her health? 2) In population medicine, what incentive does the consumer (patient) have to economize -- to behave responsibly in the financial sense?
I eagerly solicit your comments.