Why health reform is going to be difficult, and the trouble with saying no to American patients

How do we control health spending?

Most strategies boil down to eventually restricting care, for instance, not paying for treatments that haven’t been shown to work on a macroeconomic level. That may make sense when you’re talking numbers and statistics, but there will be real lives at stake when reform takes hold.

Economist Arnold Kling understands what must be done, but imagines a scenario where his daughter hypothetically was diagnosed with cancer.

“Imagine that the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200,” writes Mr. Kling. “Would I want her to get that treatment? Absolutely.

But look at the issue from a rational, bureaucratic perspective. You have to treat 200 patients at a cost of $100,000 each in order to save one life, for a cost per life saved of $20 million. Is that what a rational bureaucracy would do?

A rational bureaucracy would not even tell the family about this treatment option. But I think that in the American culture regarding medicine, I would find out about it.”

Indeed.

American medicine has been used to offering the latest and the best to patients for a long time. With this mentality, where very few treatment options and diagnostic tests have historically been denied, it will be very difficult for both doctors and patients to accept access to every conceivable health care option being restricted in any way.

Comments

Anonymous
My husband is an ER physician, and most of the patients that he sees are the uninsured seeking medical care for conditions that should be seen in a clinical setting. These ER visits are rarely paid for by the clients. Many small community hospitals close up due to this type of situations. They literally go bankrupt. He sees health care reform needing to start with making health care accessible to all. We have a Type 1 diabetic that is uninsurable. We pay out of pocket for all of his medical cost. We have the ability to pay his cost, but why is fair for someone who rides a motorcycle without a helmet willing, has an accident, and eats up hudreds of thousands of dollars of health care money have more of right to health care than my son, who by no choosing of his own, has an incurable disease? This is what we mean when we say health care reform. We don’t mean say no. We mean make things fair. We see 100 year old patients left on life support for months because insurance and/or medicare will foot the bill;but my 60 year old neighbor has to choose between food and medications. This is the why health care reform should move through before the end of this administration.
SarahW
It is not the place of the physican to “say no” because of cost. And the role of the physician is limited to explaining risk and benefit, and recusing himself from treatment plans he thinks are unwise. Treatment should be tailored to individual cases, not herds, and patients are the ultimate arbiters of whether pain and money and risk are worth benefit to be gained.
I have no problem with insurers setting limits on coverage. But a severe problem with physician colluding with herd management.
maria
That frustration hits me when I hear of my uncle in Germany who has to wait for his next chemo treatment because the doctors are on forced “holiday” due to lack of funds to pay them.
Money and medicine do seem to be confounding variables, especially here in the U.S, when looking at “reform”.
Anonymous
Where do the overtreating physicians fit into the model? Some “treatments” are unwanted and unwarranted, yet are pushed on the patient, some of whom do not even want the treatment. Unnecessary cesarean births, “prophylactic” female castrations and hysterectomies are a few of the common controversial treatments pushed by many physicians, the merits of which remain under heated discussion. Dr. Kevin has addressed the overtreating problem here.
The child with cancer MAY profit with her life by undertaking expensive and uncertain treatment, but the physicians who flog excessive and profitable treatment to their patients profit de facto.
A rational bureaucracy would also shine the light on corrupt physicians, wouldn’t it?
I agree with SarahW : the patient should be at the center of medical decision-making.
Michael
“at a cost of $20 million.”
This is most certainly a wise and rational investment. The government should make FAR FAR FAR more money off the taxes paid by this individual and their descendants than they would if she died and had no children.
Content Hospitalist
SarahW:
I would say there has to be a caveat then: payment up front. That way the hospitals aren’t the ones left holding the bag.
The problem I see is with admissions. For example, I have no medical indication to admit a patient but “they don’t feel safe going home because they live alone”. I hate to say it, but, call a friend. Make friends. We admit you for a couple of days, Medicare won’t pay because it isn’t deemed necessary, and the patient may or may not pay. I work at a not-for-profit hospital and people are starting to lose their jobs.
Last night I readmitted a pt who was discharged 2 days before. His first admit was an MI complicated by crack-cocaine use. Got a couple of stents, some new meds, sent home. I readmit him after he goes home and smokes crack for 2 days and doesn’t take any of his meds. I say that if he can’t pay for the hospitalization up front, no admit. You got your chance, buddy. Because we know Medicare (yes, he was of Medicare age) isn’t paying for a readmit within 30 days. Guess someone else just lost their job. I feel that as a physician, I AM responsible for this. We worry so much about the first three principles of ethics (do good, do no harm and patient autonomy) that we forget about the last one – social justice (including rationing so that health care is more available to everyone.)
stargirl65
I had a patient come in today. His back hurts. He already got his wife’s boss (a physician) to call in prednisone for his back 2 days ago. He is taking his wife’s percocet (which he most likely does not need) and he came to see me today. He had this 4 years ago and got a shot in his back and it was better until now.
After listening I told him that he was receiving appropriate care and I was not sure why he was seeing me. He stated “I want an MRI of my back just to see what is going on.” I advised him it was too early and wait a bit. He does not require an MRI according to standard medical care. He insisted. Insurance denied it so I told him he could pay cash if he wanted it now.

Why health reform is going to be difficult, and the trouble with saying no to American patients

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