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Saturday, July 18, 2009

Why we need to ration health care

If we ever get a real dialogue going on intelligent rationing of health care in America, I would be quite optimistic about our future as a people. If we do not achieve this result, then I would be less optimistic.

For we all know that when it comes to economics, the basic issue is/has and always will be about how we spend our money as a people. Yet sadly we have moved far from this fundamental truth as a collective.

Take the whole discussion around preventative medicine. While I want to make it clear to everyone that I am a strong proponent of spending even more money on preventative medicine, still anyone who thinks preventative medicine reduces costs ignores a basic truth of mathematics which I will illustrate below.

But perhaps more fundamentally, anyone who thinks this has forgotten the basic fact that we will all die of something one day.

Let me illustrate with a rather gruesome example to simply make my point:

Scenario A- Society spends nothing to prevent illness. As a result of neglecting preventative medicine, people sadly die at the relatively young age of 55. And while their death can be from anything, in this example, let's say they die from a heart attack and that society is willing to treat them in death with $300,000.

Scenario B- Society spends $1000/year per person preventing cardiovascular disease. As as a result of this increased spending on preventative measures, people die at much older age 75 but then they do eventually die. Their deaths might be from cancer or another illness, but they do still die. To illustrate this point, we'll also assume these different methods of death also cost $300,000.

Let's add up the costs for the different scenarios...

Scenario A: total cost $300,000/person (people live to 55)
Scenario B: total cost: $375,000/person (people live to 75)

Remember, as we all eventually die, the cost of treating our second method of death must still be taken into account when we think of how preventative medicine saves money by preventing the cost of the first thing that would have killed us. Increasing the age of our death is a great deal but we must not forget that it still means we swap one expensive illness for another at life's end. Sadly death is still inescapable for all of us- in death we are all truly equal.

Now let me illustrate the effects of rationing- and please note that I am not saying rationing must be done by either the government or the market, I am simply illustrating the effect of rationing. As it should be clear from the following example that it is rationing that gives much greater value for our health care dollar.

Say we take the same two scenarios from above but include the concept of rationing at the end of life. This might look the following way:

Scenario C (no preventative spending AND rationing at life's end): total cost $0 (people live to 55)
Scenario D (preventative spending AND rationing at life's end): total cost: $75,000 (people live to 75)

Obviously, of these four scenarios (A,B,C and D), the best VALUE in health care spending is scenario D- i.e. we spend lots on preventative services but not much at the end of our life. In scenario D, people still get to live to 75 but at a cost of $75,000.

Scenario B also gets us to age 75, but at a cost of $375,000/person which is obviously considerably more expensive than $75,000. You can decide how you want to spend this new found money (research to prevent more deaths?).

Now I realize not all end of life illnesses are equally expensive, but never make the mistake of thinking that the ones we have earlier in life are more expensive than the ones we have later as this is most decidedly often not the case.

Again, I use this rather gruesome illustration simply to make a point: when you hear people talk about how preventative medicine saves money, please realize they are incorrect, it was always the rationing that saved the money. Preventative medicine ALWAYS increases spending though it is much better value for the money we spend.

And for those of you who missed Peter Singer's NYT article, I highly recommend it.

Only rationing will save us from an otherwise national calamity and hopefully as a people we can move on to a more intelligent discussion around this issue.

In my next post, I will describe why rationing has nothing to do with private or public medicine and why either system can incorporate rationing fairly.


Dink said...

When Haidt spoke of liberal "Puritans" substituting food control for normal Puritan sex control it felt a little "close to home".

Yeah, I'm a zealot. No coffee, no beer, no meat, no cigarettes. Go to the gym, take walks (on that note, didn't Thai once have a link on Sudden Debt from a doctor who said hard-core cardio like marathon running was bad for humans? It made me happy because I agree).

The gym membership and organic foods may increase costs, but most preventative maintenance is free (walking/strength training) or actually avoids expense (wine).

Thai said...

Dink, wine is a most fascinating one. While I am the very first to ask my patients to reduce their alcohol consumption, are you really sure you have thought about all the issues surrounding wine/alcohol?

I had a friend in sales who was a teetotaler, she would have told you right away it was a major factor that limited her career.

Don't ever underestimate the power of social bonding/cooperation nor the things that improve social bonding.

All our wealth as a species comes from cooperation.

Thai said...

Now if this sustains itself, it will have a major positive impact on our economy.

I was always hoping that the election of Obama would herald in something like this but who knows if they are really related?

Dink said...

A teetotaler can still play reindeer games. The others may at first be leery and assume you're either a recovering alcoholic or mormon, but this period is brief.

And most studies I've ever seen about the health benefits of wine seem to say that red wine is relaxing and since stress is bad for you, relaxation is good for health. The subtext seems to be that the mind (one of them or part of one?) is a stressor and needs to be chemically neutered into submission.

Really glad to hear about the crime drop. Freakonomics noted the legality of abortion limited the number of unwanted kids who were then hitting the golden crime years (15-25 y.o.), but this was about 10 years back. Having 1% of the criminal population in prison has to be involved. Childhood obesity. I'm sure its an interesting mix of causes.

Debra said...

On the subject of wine :
Next week I will be heading off into the region of France which is called the Côtes du Rhone septentrionnels.
These are wines that the Romans were familiar with (although you wouldn't have wanted to taste the filthy stuff that the Romans drank before REAL winemaking came into being...)
Côtes du Rhone septentrionnels : Condrieu, one of the finest white wines in the world. Tain l'Hermitage, a very very nice red wine. Côte Rotie, one of my very favorite red wines in the whole world. And this time, I am going to try to get my tastebuds around a Cornas, old vinification style.
Most Americans know nothing about these wines. Almost everybody has heard of Bordeaux, and Bourgogne, and thinks that the Côtes du Rhone are cheap second rate wines. Not true.
Teetotaler ?
That's a PURITAN concept if I ever heard one.
Kind of like American society has resurrected Puritanism in the current hygienic trends. No money wasted on the gym in my household. I am too much of a loner to go hang out at the gym.
I will get back to you on the joys of the Riviera.

Debra said...

Just a friendly jibe, Thai.
I am mystified as to why so many people are selling the joys of a SINGLE PAYER health care system in the U.S.
For info, IN PRINCIPLE AT LEAST, France does NOT have a single payer health care system. Employers AND employees contribute to the system, and the caisses also have their say. It WAS a rather complicated system before the government's raving desire to get its hands on it, and the government's decision to let employers NOT pay their dues, dealt it the deathblow.
For info : single payer, in my mind is like... putting all your eggs in one basket. You don't want single payer for the SAME reason that you don't want... A KING. Too much decisional power concentrated in too few hands.
But I'm not really up to date on your debate on the other side of the Atlantic...

Dink said...

How kind of Bacchus to stop in and remind us of the importance of hedonism ;)

"resurrected Puritanism"
Obeying the rules of science in hope of being granted longevity. Pretty watered-down from the original Puritans, yes?

Interesting short article in Scientific American this month: Apparently people with Down's syndrome rarely get tumors. Five or so of the genes on their duplicated chromosome apparently regulate blood vessel creation. So they have extra "cops" which prevent any enterprising criminal cancer cells from growing a blood supply.

It would be interesting to offer people an option regarding SS's end-of-life dollar figures: use the money on yourself or the money can be donated to research on eradicating the disease that attacked you. Be it generosity or revenge, I'd bet there'd be big donations.

Thai said...

Dink, are you sure? I think this current spending mess we are all in is an rather clear indicator of how people really vote when the rubber meets the road..

Deb, while I am agnostic on the issue of single payor, if you were to force me to chose a side, I would probably agree with you and vote against single payor.

I too think the increased systemic risk that comes from totally centralizing a system is probably not worth the small improvement in inefficiency gained by centralization.

... But you have to realize that is against the law for Medicare to ration (by federal statute). I think the real issue (behind the smoke screen of "single payor") is a hope on the part of certain reformers that once a single central payor has been instituted- it will be even easier for them to institute rationing- covertly.

And while I am completely in favor of overt rationing, I am totally opposed to covert rationing, which this blog is wonderful at exposing with humor.

Covert rationing is unbelievably destructive to social cohesion (imo).

If you follow the debate in America, the language being used is "we need to spend more now to save more later".

I have thought long and hard on this issue and my simplest translation: covert rationing

Debra said...

Thai, in my opinion, ATTITUDES need to change on the question of health care and priorities.
I think that the demise of CLINICAL medecine is the number one culprit for exploding health care costs. Translate : the demise of clinical medecine = the industrialisation of health care.
In the same way that we are going to have to pull back from industrialized agriculture, we will have to pull back from industrialized medecine. The problem is... industrialization, in my book at least.

Dink said...

"Dink, are you sure?"

No, not sure. I read that there's an interesting phenomenom in Oregon with regards to the right-to-die law. Apparently people get the lethal prescription from their doctor, fill it, and then just keep it by their bedside until they pass away naturally. People like having the option even if they don't use it. Controlling the fear of the unknown I suppose. WA passed similar legislation last year and many hospitals said they won't deal with it. I get the impression their refusal was due to bureaucratic issues versus philosophical issues.

On a different note, I read that Jordon is stepping up its medical tourism advertising. Round trip tickets for the patient and family, surgery, and a vacation for less than 25% of what you'd pay in the US. Canadians and Europeans are joining in as well due to long wait times for procedures. Supposedly the surgeons are US trained and the staff all speak English.

Thai said...

I have a lot of end of life discussions with patients (and I mean a lot) and their families. One thing I have learned: it's impossible truly see death from the vantage of someone who is really about to face it and knows it.

All studies on end of life/living will decisions have come to this same conclusion- that people really don;t know what they are saying in advance and that they will likely change their mind as their illness advances.

I have lost count of the times people have told me "don't do X", only to completely change their mind when the moment comes- understand I ALWAYS respect whatever new wishes my patents have... Indeed go out of the way to make sure the want to stick fast with their prior wishes- death does not allow second chances.

So I don't really have an answer for this- and I completely agree with Dr Rich that society has an inherent conflict of interest in promoting the right to die movement- AND the issue is what it is.

We make choices on how many kids we will have and economic reality plays a role in that decision. Why would be think the same not be true about choices concerning death when we live in a finite planet.

My only point is that when it comes to collective resource decisions, we do need to be both intelligent and consistent with each other.

If we are not consistent (at least reasonably so as it will be impossible to be truly consistent), social cohesion will be in trouble.

Thai said...

Deb, you make a valid point re: demise clinical medicine and increasing costs.

But I think this general line of reasoning, particularly popularized by Obama's policy wonks who propose we shift funding from more expensive and more complex sub specialty care to less expensive and less complex primary care- for the record, EM is considered a primary care (just to give full disclosure).

Perhaps the following example might help illustrate the dilemma: chest pain.

Studies are quite clear that the more patients with chest pain who are admitted to the hospital, the few heart attacks that will be missed. And the more patient's with chest pain who are sent home, the more heart attacks that will be missed.

If is a fundamental truth without solution. It eventually becomes one of those "what is the heart attack diagnostic threshold you are willing to tolerate?"

For the truth is people really want good outcomes. If your husband visit America and you get a call saying he has gone to the Emergency Department with chest pain, all you really care about is whether he has a good outcome or not. If that good outcome occurred from more use of clinical medicine all the better, but if it occurred through heavy testing, it is still probably the good outcome that matters most to you.

Studies are quite clear, while clinical judgment alone It is clear that clinical judgment is good enough in some circumstances, it is not in others. Sometimes it is made much much better with technology and this is another fundamental truth we cannot escape.

Of course if we are all poorer, it will be all we can afford.

If we are all richer, we can afford it.

It gets back again to how you want to spend your money.

Spending 20% of all monies that were originally saved for retirement on a growing few who can use it by claiming new and exciting ways to go on disability (I think this number is closer to 30-40% in France/other European countries) is a sure fire way to guarantee the only thing people will be able to afford is care with worse outcomes by primary care clinicians.

How do you want to spend your money??????????

Dink said...

From the Dr. Rich link:

"one striking finding - hundreds of times each year, acts of involuntary euthanasia are occurring. That is, patients are being killed under the Dutch healthcare system at the hands of their doctors, without their explicit permission. All these patients, it is claimed, are being euthanized for entirely humane reasons."

Huh? These are open, active, documented mercy killings?

"new and exciting ways to go on disability"

This really is a huge problem.

FYI, please don't think me rude if I don't log in again until this weekend. Even the Summer can get squirrely sometimes.

Debra said...

Thai, it is funny that you should come up with the chest pain problem. BOTH of my parents died of heart attacks ; BOTH of them were in health care professions (my dad was a forensic pathologist... !!!!), and both died prematurely from the point of view of our current society.
Ironic that BOTH had the diagnostic skills to realize that they were at risk of a heart attack, and that NEITHER made this diagnostic. (In my dad's case, he was followed scrupulously by the town's best cardiologist who was literally blown away by his death, and asked for the autopsy that determined that he would have been an invalid had he lived AFTER that last heart attack...)
And I have realized as a shrink that heart attack intervenes in particular circumstances : i.e., when an individual is BETWEEN places or functions, when he/she has FINISHED one task and is in psychological limbo for what's coming up.
I have also realized, as Freud realized, that our unconscious mind KNOWS things that our consciousness rationalizes to give it an "acceptable" form and content.
A grisly example : my daughter's 18 year old classmate who died last year of viral meningitis proclaimed to a friend during the incubation period that he was not worried or interested in getting his driver's license (a big big deal in France where it is almost like trying to pass the bar exam...) because HE HAD THE REST OF HIS LIFE IN FRONT OF HIM TO DO IT.
Freud picked up on this type of phenomenon : just BEFORE you break out in your favorite psychosomatic symptom ( i.e. rash) you come out with "hey, that's great, it's been a long time since I broke out into a rash...". That's the mind's way of acknowledging its perception that the rash is ALREADY in preparation...

Thai said...

It gets back to what kind of outcomes you want.

Dink, from the NEJM (New England Journal of Medicine): "In the Netherlands, approximately 3100 cases of euthanasia and 550 cases of physician-assisted suicide occur annually, representing 2.3 percent and 0.4 percent, respectively, of all deaths"

SS said...


I realized I missed you guys, the comments remind of something I posted recently as commentto another site. It has to do with Puritanism, sexuality and insecurity. Think I'll throw it up for you guys to devour.


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prady said...

is it really worthwhile paying thousands of dollars of public money to increase lifespan by 3 weeks?
here i think we would need rationing of healthcare. who decides on it? family or the doctors or govt?

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