Covering “Effective” Medical Services

Posted on January 2, 2009
Filed Under General Rationing Issues |

A reader responds to DrRich’s recent post on strategies for preserving our individual prerogatives under universal healthcare:

I believe your post to be logical if proven, highly effective treatments are indeed withheld by the universal system. . .The best counterargument by proponents of the universal system would be to make it very clear just what “highly effective” means. It could also be pointed out that in the past a great deal of snake oil was sold to unwary, desperate patients. If such an effectiveness campaign was done correctly, I am not sure just how much demand for “maybe effective” medical services there would really be. I certainly hope that any truly effective healthcare services would be made available in the universal system, however!

DrRich congratulates this Dear Reader for getting into the appropriate frame of mind for the new era that is now dawning upon us. For, when confronted by a host of growing and seemingly intractable systemic problems, we have clearly seen that in this new era our main task as Americans is to: a) elect dynamic new-era leaders who will utterly change the way these problems are addressed, and b) hope audaciously.

Accordingly, like his Dear Reader, DrRich hopes that all truly effective healthcare services will be made available under our universal healthcare system. DrRich also hopes to win the Pennsylvania lottery this week. Both of these hopes are suitably audacious.

It is not possible for the healthcare system to buy for every American all the healthcare services that would benefit them. This is why rationing, in one form or another, is unavoidable. (DrRich will not try to prove this fact again here. He has offered proof many times in the past, including on this blog, on his website, and in his book.)

So the real question we should be asking those who are going to reform our healthcare system is: How are you planning to ration?

There are ways to devise a system of open healthcare rationing that would result in fair, effective, efficient healthcare, and that would actually minimize the number of effective healthcare services that will end up being withheld. But to accomplish this, we would have to openly agree to ration.

DrRich has not heard anyone in a position of authority, not even anyone from Mr. Obama’s team, a team that promises to set new standards of openness and transparency, mention that healthcare needs to be rationed.  Thus, as much as DrRich would like to feel all new-era-y, he suspects that the rationing will continue to be done covertly.

So here is what DrRich fears we will see in the way of deciding what to cover and not cover under our new universal healthcare system:

Mr. Daschle has famously proposed a Federal Health Board (”Fed Health”), modeled after the Federal Reserve, to make major healthcare policy decisions. Nobody knows what this will actually look like, of course, but behind all the palaver about accountability and transparency, the Fed Health will probably be making closed-door (or ostensibly open-door but ultimately political) decisions about which healthcare services will be included under the universal system.

Since they (by definition) will not be rationing healthcare, the Fed Health will therefore not be able to say things like, “While medical service X is indeed highly effective in 15% of the patients in whom it is applied, that degree of benefit does not justify the very high expense of this medical service. Based on our published rationing criteria, therefore, we cannot provide medical service X under our plan.”

In other words, Fed Health will not be able to discuss publicly the medical services that are, say, at least partially beneficial in a substantial minority of patients, but are too expensive to cover.  Instead, they’ll have to say, “This medical service doesn’t work, so providing it is wrong.” (If providing it is wrong, then withholding it is not rationing.)

Thus, the strong tendency for administrators of our universal healthcare system will be to divide the galaxy of medical services into two broad groups: Those services that are highly effective and/or relatively inexpensive, which will cheerfully be provided to one and all; and those services which will be declared (after careful study and analysis) to be completely useless and probably harmful (not to mention expensive), and which will not be covered.

Furthermore, any health professional who attempts to provide services from this latter category (since those services are ineffective and harmful) will be guilty of crimes against humanity, and will likely forfeit their careers, life savings, and freedom. Indeed, DrRich supposes that the Obama administration may eventually see the wisdom in keeping Guantanamo open, if for no other reason than to have a suitable venue for detaining these healthcare terrorists.

Please understand that DrRich is not complaining. Such a system, as odious as it sounds, is substantially better than what we have now. Today, we have a healthcare system that claims to cover “everything,” then conducts most of its rationing by coercing doctors to act against the best interests of their patients.  Under the system DrRich has just described, a) at least some of the rationing decisions will be made away from the bedside, by the Fed Health, and will be less destructive of the doctor-patient relationship; b) the black and white pronouncements of the Fed Health will not go completely unchallenged, and eventually the feds will have to become more open about their rationing decisions; so c) it is possible to visualize how such a system might evolve, some day, to one where open rationing is conducted under a process of actual transparency.

But DrRich urges his Dear Reader to be less “hopeful” and more skeptical about coverage decisions.  If one is mired in hope, then it will be all too easy to just accept on its face the black and white pronouncements of the Fed Health regarding which medical services are “truly effective,” and which are “useless.”  Many if not most medical services fall somewhere in between these extremes.  Therefore we will need to hold the feds’ feet to the fire to make them accountable for their decisions. Demanding accountability and transparency will eventually yield rationing decisions that are much less bad.

But no matter where or how you draw the line between covered and not-covered medical services, we will still be rationing. And that means that at least some beneficial medical services will always be withheld from at least some people.

And that, Dear Reader, creates a demand for out-of-system healthcare services, no matter how you cut it. The basic message of DrRich’s previous posting, therefore, still obtains.

Comments

9 Responses to “Covering “Effective” Medical Services”

  1. Annie on January 2nd, 2009 10:15 am

    Isn’t it interesting that there is so little leakage coming from the Obama team about what the structure and processes of healthcare reform are going to be?

    One point I posit that may be worth a look see is the notion that treatment and care are different animals. More care is needed, while more treatment may not be. Care is what is encompassed by assessing, educating, counseling, supporting, coordinating and coaching to facilitate patients’ self care and healthcare choices and decision making.

    It’s the foundation of the physician/nurse-patient relationship. it’s the biggest satisfier of direct care providers and patients, and it isn’t reimbursed or rewarded. It’s also at the root of providing treatment and services which do not contribute to preventable errors, patient suffering, patient harm and patient deaths.

    I wonder why we don’t spend more time discussing this since I posit, if there was more care, there would be lesser primary care shortages, a more mitigated nursing shortage, and higher patient compliance.

  2. pcb on January 2nd, 2009 3:03 pm

    “It is not possible for the healthcare system to buy for every American all the healthcare services that would benefit them. This is why rationing, in one form or another, is unavoidable.”

    This should be a header at the top of every health care/policy blog, and repeated before every meeting held anywhere regarding health care reform.

    Until we get this simple, yet profound, point understood, meaningful reform will remain elusive.

  3. Bad Medicine, Good Solutions on January 2nd, 2009 5:08 pm

    Great writing, keep spreading the word. I wrote a slight off shoot piece that stemmed from your two blog entries. I thought you might like to know.

  4. CancerDoc on January 4th, 2009 4:08 am

    People seem to have their head in the sands. Why do we ask whether a 92 year old with dementia who is bed bound should be a full code? The chances for survival are minimal if they come to a code, but the opportunity for generating a huge bill is high. Why do we ask if a patient with metastatic carcinoma with no remaining treatment options is a full code? Once again, the chance for meaningful survival after a code is minimal, but the opportunity to run up a bill is high.

    So much of medicine in our society is about managing chronic, and in many cases what proves to be catastrophic, illness. Just because we can doesn’t mean that we should. So often, physicians continue care for reasons that are very unclear, but often, I see the care driven by families. (Granted, in some cases, the care originates from the physician’s own discomfort with death, or the physician’s discomfort with the conversation about death. That’s another issue.)

    I believe that our media does a huge dis-service. They report the exceptions — the patients that survive despite the doctors that pronounced (usually in a quite reasonable fashion) little chance of survival. Therefore, many families feel the “right” to drive futile care, with the thought that their relative might just be that one in a million miracles.

    The question remains, how many miracles can we afford?

    In the state where I practice, no physician is required to invoke futile care. However, I have yet to see a case where care was not given when a family or patient demanded it. There needs to be a greater societal understanding that life is a process that leads to death. “Bad outcomes” will happen; however, from my perspective, the bad outcome might just be the natural conclusion of life.

  5. NG on January 4th, 2009 7:56 pm

    Dr Rich said:

    “But no matter where or how you draw the line between covered and not-covered medical services, we will still be rationing. And that means that at least some beneficial medical services will always be withheld from at least some people.”
    ———-
    A lot here that only speculation can address at this time. Rather than guess what will be covered and what won’t, let us at least try to focus what is done on that which is truly needed in the first place even if covered by the universal system. What I would like to discuss/point-out is that financial incentives foster by a fee for service system automatically leads to more treatment from a supplier financial welfare point of view. Unless we want to police the system from a total top down review of everything point of view (as if that’s even possible), can we at least foster that only truly needed care is rendered by making the financial incentives to providers such that the providers do not overly benefit from over treatment or useless treatments at the margins??

  6. sayspine on January 6th, 2009 10:15 pm

    1/3rd of ICDs under current guidelines (850 million yearly) should be at the top of the “unnecessary list”

    Spinal fusion surgery (w/pedical screws hardware)-right behind the unnecessary ICDs

  7. Ted/Galt-In-Da-Box on January 10th, 2009 6:11 pm

    Healthcare rationing (or “resource allocation”, as the FULSOBs in existing SocMed countries call it) is not about making sure everyone has everything.
    It’s about making the bare minimum necessary available to the proletariat, while the pull-peddlers in government and their looting friends, relatives and supporters in the bureaucracy are well taken care of.
    Lest we forget, the only actual difference between corporatism and communism, is that the OMFR that run the corporations in the former, own by way of the government in the latter.

  8. Rivenburg on January 13th, 2009 9:57 am

    Rationing medicle services is done in any type of coverage, public or private.
    In the “free market” coverage the bulk of us ..enjoy.. we get what we can pay for, that’s a form of rationing, a “rational” form of rationing (for the most part). I have personaly seen THIS system doing non-rational care though, both driven by the familly and by greed, doing full code resesitations against personal and familly requests, even documented requests. Not quit as rational as I would like to see since it wastes finite resources. But who is going to make the triage call?

    My fear with this new administrations version of health care we may well get a politisized triage, AIDs patents may well get preferential treatment even though they are the needle using dregs of society and their desease takes the resources that could save several real people with jobs and no criminal record, no needle tracks.
    Face it, you got needle tracks, you’ve already surrendered part of your humanity right there.
    This is were the free market forces shine, non-working scum dont get what hard working people can get, unless the socialists work their income-redistribution schemes.

  9. Marty on January 13th, 2009 5:32 pm

    I do not work in the health care field, but my wife has a severe, non-life-threatening, uncommon but not really rare, and non-sexy chronic condition (Complex Regional Pain Syndrome) and I have worked in govt for 30+ years, observing and participating in the political/governmental process up close–and I offer that for all the problems with our current system, the thought of politicians and their appointees deciding what treatment my wife can and cannot have makes my blood run cold.

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