Health Care Madness IIc ! Rationing and Adjusting the Incentives

The author (not Simon Johnson) of this post at The Baseline Scenario (found via Some Assembly Required) operates on the very logical assumption that rationing exists and will continue to exist, and tries to devise a not-too-complex (it’s health care.  It won’t be simple) modification to our current system, in broad strokes, that would accomplish many of the goals being sought after.

Go check it out.  Lots of jazzy charts to start and a simple proposal to end with.  The assumptions are fair and logical, without being unduly laborious in supporting references, and the outcome itself is palatable to almost all parties.

… and the cow goes moo

Health Care Madness IIb ! A Brief Addendum…

One more thought on my last post:  I wonder how many people who express such fear and contempt over the idea of rationed care are organ donors themselves?

I am, mostly to gain karma points with the Gods above who decide whether or not I should be catapulted from my motorcycle.  And those people on television are old.  I’m young and my body is pretty.  You must agree that allowing to have mine chopped up would be the greater sacrifice.

But how many of these people on TV who express outrage at the idea of granny not getting the health they deserve have signed on to have their corpses cut up to reduce the number of people dying on waiting lists?  Do they care enough to donate chunks of their soon-to-be-rotting corpse?  Or just enough to donate their outrage?

… and the cow goes moo

Healthcare Madness II ! Obama Will Ration My Mama’s Meds!

(this was supposed to be a more frequently-updated series; I’ve been meaning to follow-up this post for quite some time)

One of the interesting, but entirely misrepresented (intentionally at times, due to ignorance and parroting at other times) concepts considered at the center of the debate would be: RATIONING.

Rationing, triage, actively deciding who gets what, or constructing a system that makes the decision based on certain factors is a very interesting and messy topic that no one wants to talk about, but that is what rationing is.  And that is the decision afoot.

The debate, not surprisingly, revolves around the word and the negative connotations to it (ideas of poverty and government distribution) rather than the very complex matter of actual rationing.

The fact is, when someone doesn’t get the exact medical attention that they desire and could benefit them, we are looking at rationing.  And believe it or not, in Barack Obama’s America and even before it, we will have medical rationing.  Sadly, this is a statement so obvious that it rarely merits mention.  Sadder still, some people seem to be unaware of it entirely.

The entry of the term “rationing” in the health care debate has been KILLING me for the past few months, as no one seemed willing to point out the obvious that health care is rationed to a much greater degree now than should any prospective plan including a public option or insurance mandate be enacted.

Thankfully, this very obvious fact is finally making inroads, warranting mention in Jon Stewart’s unwatchable mess-of-a-debate with Betsy McCaughey (CDN link here, US here), the one informative bit of that entire 10 minute trainwreck, and getting solid treatment in this Matt Taibbi blog posting about the attractively pouty and vapid Maria Bartiromo’s interview with Congressman Anthony Weiner.

Taibbi’s post is, as usual, worth reading in its entirety but here is the segment that I hope to see more of:

“It drives me crazy when people make this argument. Fuck a fancy boutique drug like Erbitux — I have a very expensive private plan and I can’t even go to a doctor, not even to ask a simple question, unless it’s an emergency. [...] Hell, forget about paying for Erbitux, if I wanted to get a colonoscopy to find out if I needed Erbitux, I wouldn’t be able to — I’d probably have to wait until I was a fully symptomatic cancer patient before I could even have that conversation on my insurer’s dime. And I’m one of the lucky ones, I actually have money to pay for care out of pocket, if I had to. No country in the world rations care more than the U.S.”

Exactly.  Why does it take the closest thing we have to a renegade major journalist to point out that Americans don’t get all the treatment they want either!

Worse yet, uninsured (or under-insured, or simply less wealthy) Americans may be prone to skipping out on the most cost-effective care: preventive care, as Taibbi implies.

The great fear, living under an Obama regime, is that a screening system would be designed that would preclude older people from getting the best treatment available if the costs were too high to justify (by some crazy liberal metric) being spent on someone who might not live that much longer regardless of the care they receive.  Kind of like those organ waiting lists that everyone-but-Steve-Jobs is mercy to: With a finite resource such as transplant organs (as opposed to the apparently infinite resource of health care dollars), we must invest wisely.  Currently in America, organs are provided to those in greatest need, with the highest chance of benefiting (i.e. surviving the transplant and extending the quality or length of life as a result of a successful transplant).  Oh, and being “a youngish, white male with a big bank account and great health insurance” helps too, according to this article interviewing Dr. Benjamin Samstein, MD, assistant professor of surgery at Columbia University College of Physicians and Surgeons.  Of course, being youngish is less important if you’re a man of means, say $6 billion or so, who can move to Memphis to get equal treatment to locals on a much shorter waiting list than that of his actual state of residence.

Now, how horrible does applying the terms of transplant organ distribution to other forms of medical treatment sound?  As the good doctor Samstein says about organ ‘rationing’: “one of the fairest and most advanced we have for the allocation of healthcare resources here in the US.”

If politicians who support health care reform would just admit that there, of-fucking-course, will be rationing under any new system, and just explained how an imperfect system would be devised to replace our currently very imperfect system, we might be able to choose between the health care options that provide the best, you know, care.  And in an even crazier world, we could have a real debate about who Americans think deserve and don’t deserve every degree of care available.  Rather than trying to throw scary sounding words at a reform movement and hope they stick.

HEALTH CARE IS A FINITE RESOURCE, MOTHERFUCKERS!  HOLY CHRIST!

[Sorry.]

… and the cow goes moo

Healthcare Madness! A comparison between the Canadian and American health care system

I thought I’d pull together a bit of a collection of points and points of view in regards to the debate on health care.  The debate over health care is probably the most significant political discussion Americans will have during the Obama presidency, so I couldn’t pass up mentioning it.  And it happens to be a subject where I, as a former pre-med student, have more than a passing curiousity.

There certainly is a lot of noise that can be left out of the discussion, but this is one of the most important and appropriately handled political discussions that I have witnessed.  There is a fair ratio of sound-minded opinion and factual presentation to character assassination (very little so far, outside of the usual Obama-is-Black-Lenin talk) and misrepresentation and I’ve been happy to read most of the analysis that has crossed my path.  It’s like I’m in a room full of adults, for the most part.

As a Canadian who is very satisfied with our health care system, even if I am often upset with it’s practitioners and the more general prevailing approach to health care (I was born here and have never had to seek medical attention abroad, so I cannot compare directly), I enjoyed the NYT’s Nicholas Kristof’s (This Time, We Won’t Scare – June 10, 2009) anecdotal example of health care experiences from someone who had to experience both the Canadian and US approaches in succession.  Certainly as anecdotal evidence, it is meant for memorable impact more than analysis, it nonetheless manages to include a very important part of the debate that may be under-represented in statistics:  The experience.

The article points out two very poignant facts that are often overlooked as being perhaps more of emotional value then practical value, but in the field of medicine where impractical emotions can have drastic effects on physiological and behavioural responses to treatment, I would argue the lack of attention to matters such as these represent an ongoing failure of medical practice.

The two facts Kristof (and his subject, Diane Tucker) bring to the fore are: (1) the creature comforts that can be lost in a medical system like Canada’s, where there is less of a first-class and economy-class segregation of medicine (though you can certainly pay to get more even in Canada, the ‘more’ in question is irrelevant to the actual treatment); and (2) the apparent weighting of priorities in the US system, between treatment and payment.

Kristof’s subject, Diane Tucker, pays the paltry sum of $49/m for her health coverage as a Canadian resident (a deal even from my perspective, as a 20-something year old with heart like bull) and for it she receives prompt emergency service and initial response, albeit in less luxuriant quarters and with high school cafeteria-level food and perhaps (depending on what tier of American health care you wish to compare to) longer wait times for health visits required for non-emergency concerns.

The more acute and shocking revelation in the article to me, as a Canadian, is the clear message being sent by medical corporations in America when services are needed:  Before we decide to treat you, we have to be sure you can afford to pay us for it.  Apparently the first thing that Ms. Tucker needed to do when she visited a US hospital was to prove she was afford the treatment she required (or for the hospital to ascertain how much ‘treatment’ she could afford to obtain… I’ll get back to this in a second).  Perhaps I am misinterpreting this aspect of American health care, but to me the message is clear:  Prove to me you are worth helping before you prove to me you need helping.

Kristof spends much of the rest of the short article assassinating (justifiably) the character of some of those spearheading the movement against anything approaching universal health care, which interested me very little.  But the contrast between Canadian and American treatment approaches for Ms. Tucker are worth considering befor ean outcome is reached.  Weigh out the benefits of one system over the benefits of the other before you pick a favorite.  And please keep in mind what medicine should be.

[Note: I plan to continue commenting on this subject over the next bit, as I already have a few other articles and news sources saved.  Time permitting.]

… and the cow goes moo

Paul Krugman Advocates Shock Doctrine Imposition of Universal Healthcare!

Krugman has been an outspoken advocate of universal healthcare in America for some time, so the contents of his latest op-ed should be no surprise to anyone who has read his editorials before.  Especially those who read his editorials during the Democratic primaries, where the major candidate’s slightly-varying stances on healthcare appeared to be his primary reason for his support of Hillary Clinton and John Edwards over Barack Obama.

But I wonder if those on the left who love Paul Krugman and also Naomi Klein’s The Shock Doctrine will find it odd that Krugman would propose the nationalization of healthcare in America during a time when the nation is struggling with the great economic disaster in any of our lifetimes (I’m trying to avoid the oft-used “since the G____ D_________”.  Do eighty year olds read blogs?).

Granted there are many reasons to argue that the need for universal healthcare has never been greater, and Krugman touches on that fact, but that could be said for any disaster.  Any ’shock’ as Naomi Klein seemed to describe it — from what I can recall from reading her book a couple of months ago — could be, in my opinion, suitable justification for any major change.  And it is absurd to accuse anyone of taking advantage of a weakened society, reeling from a recent loss or ongoing decline, to advocate reform.  Who advocates reform when things are rosy?

My point is not that universal healthcare is needed now or not, but simply that any major vicissitude is going to be accompanied by calls of those who have been long advocating for a change to some kind of functioning (perhaps just barely) system.  And it can always be argued that it is both the best time to sneak a change through when a population is least equipped to consider it, or it can be argued that the change is merely needed now more than ever.  Whether it be healthcare in America or democracy and free market reform in Iraq.

… and the cow goes moo

NYT’s Kristof giving props to Canadian iodine initiative

Judging by Nicholas Kristof’s description, the described initiative sounds phenomenal.  It actually makes me feel a bit proud to be a Canadian (though I have absolutely nothing to do with the program and was not even aware of it).

The New York Times:

“Indeed, because it’s so numbingly boring, few people pay attention to it or invest in it. (Or dare write about it!)

It’s iodized salt.

Almost one-third of the world’s people don’t get enough iodine from food and water. The result in extreme cases is large goiters that swell their necks, or other obvious impairments such as dwarfism or cretinism. But far more common is mental slowness.

…

“Probably no other technology,” the World Bank said of micronutrients, “offers as large an opportunity to improve lives … at such low cost and in such a short time.”

Yet the strategy hasn’t been fully put in place, partly because micronutrients have zero glamour. There are no starlets embracing iodine. And guess which country has taken the lead in this area by sponsoring the Micronutrient Initiative? Hint: It’s earnest and dull, just like micronutrients themselves.

Ta-da — Canada!”

Congratulations, Canadians!  Apparently, we’re boosting the intelligence of the entire world, and not just by raising the average with our own smartness.

But really, this sounds like a beautifully economical way of improving the lives of millions of families throughout the third world.  I am ecstatic to provide any limited attention I could to such a wonderful-sounding initiative.

Sadly, Kristof does not provide very much information about the initiative itself, so I asked my good friend Google and found this CBC.ca article that contains more information about (what I believe to be) the program Kristof mentions.

The article reports a cost of $100 per life saved through the micronutrient initiative proposed by Susan Horton, an economics professor at Wilfrid Laurier University.

More about the Micronutrient Initiative (capitalized in this paragrap for a reason) mentioned in the article  can be found at their website here.

… and the cow goes moo

NYT: Cleveland Clinic Discloses Doctors’ Ties to Medical Industry

Let’s hope this is just the first of many medical centers to provide this tiny bit of information.

The New York Times:

“The clinic, one of the nation’s most prominent medical research centers, is making a complete disclosure of doctors’ and researchers’ financial ties available on its Web site, www.clevelandclinic.org.”

It seems like such a simple bit of information to provide but doctors have been bucking this bit of scrutiny despite the obvious import such ties could have for patients.  I believe it is largely because like anyone else, a doctor does not believe that a financial relationship with a company (say, as a practitioner-consultant for a medical device maker) would bias their own diagnosis and prescription to the benefit of that drug maker.  It is an honest and understandable assumption by a doctor — or any person — to assume that self-serving financial interests or merely constant exposure to a certain product or company could influence decision-making.  The abstract to this meta-analysis would appear to confirm this suspicion.

As promising as this move is, and it certainly is a step in the right direction (with the advent of the internet, is there any reason why this sort of information shouldn’t be made public?), I wonder how many patients are so vigilant in their scrutiny of doctors to take advantage of this information?  Furthermore, even knowing that a doctor has a relationship to a drugmaker and then being prescribed a product of that drugmaker makes for very poor evidence of bias.  I imagine — and I would hope — few patients have numerous enough prescriptions to be able ot extrapolate a bias in a doctor’s opinion.

This is certainly the step in the right direction, but will have very little impact even if every medical clinic in the world engaged in a similar degree of disclosure.  What is required is a shift among patients to a more consumer-centric mindset:  Do your research as you would for a car or a house (your health is worth at least that much) and shop around when economically feasible.  And just because your doctor is the expert, doesn’t mean you cannot ask questions to bring out the reasons for his or her diagnosis.

When doctors know that patients are informed and prepared in their own research of their ailments, then we will see a shift in behaviour away from protecting the secrecy of their financial ties and towards more responsible medicine.

… and the cow goes moo