Don Berwick, possibly the most widely respected and thoughtful expert on improving health care quality and controlling health care costs, has withdrawn his nomination as head of Medicare in the face of Republican opposition based on claims that Berwick wants to ration the availability of health care. Which is intellectual horse manure if you honestly consider all of what Berwick has written and said and done. But to whine about politics interfering with a presidential nomination is pointless, and misses the more important question. Why do people who believe in the rationality of the market about prices and supply and demand so ferociously oppose just that if you change rationAL to rationING?
Suppose you have a disease... an incurable fatal disease... and a drug has just been approved that can treat that disease. The drug only works in about half the people who get it, and all it does is lengthen their lives by an average of 4 months. Side effects include diarrhea, nausea, rash, and fatigue. Still, you couldn't get your hands on it fast enough.
But suppose the drug costs way more than you can afford, and suppose that insurers won't cover it because, they say, the drug does not provide 'cost-effective' use of health care dollars. Cost-effective!? How DARE they! How DARE some number-crunching, penny-pinching, cold-hearted bureaucrats decide what you can and can not have that might lengthen your life!!!! How dare they decide who lives or dies, based on money!!!
Welcome to the United Kingdom, where the government oversees the health care system, and where the National Institute for Clinical Excellence (NICE) that reviews drugs and treatments for the government recently recommended that the $126,000/patient cost of Yervoy, a new drug that can prolong the lives of some people with advanced, inoperable (and usually fatal) melanoma, is too high and that it doesn't provide enough health care bang for the buck so the National Health Service (NHS) shouldn't cover it. If the NHS takes that NICE advice, some people in the UK with advanced inoperable skin cancer who can afford Yervoy may live a little longer. Some who can't afford it, will die... a few months sooner than they might have.
Ugly, huh, putting a monetary price on life? But now let's change the shoes you're wearing. Let's say you're not the patient. Let's say you're in charge of the health care system, and you're asked to choose whether to cover a drug that can treat some terrible fatal disease, but which only prolongs life by a few months, and only in half the patients who get it, and many of the patients who are helped live those extra few months vomiting and weak and covered in a rash. And the drug costs so much, per person, that approving it for coverage will mean insurance rates for everybody in the entire system will have to go up, to cover the costs. Now what do you think?
To a patient, approving or disapproving coverage of health care based on a comparison of costs against benefits is rationing, in all that word's ugliest meanings... 'denying choice' and 'death panels' and 'murder.' But to everyone suffering in one way or another from the excessive cost of health care -- which is most Americans -- this sort of decision making is rational, in all the positive meanings of that word... wise, thoughtful, balanced and fair. Interesting, isn't it, how the tiny difference in those two words -- 'rationing' and 'rational' -- belies the great gulf between what each implies. In that gulf lies the heart of the difficulty in solving the health care cost crisis.
It's pretty obvious that the system can't afford everything. Analysis of health care benefit per dollar of cost is one way the UK and other health care systems are using to face that reality. The U.S., where 'freedom of choice' and 'land of opportunity' are so intrinsic to our self-identity, has not found a way to confront such tough choices. So:
- We spend more than twice as much per person for health care -- $7,538 -- as the average of all the other industrialized nations -- $3,060.
- More than one dollar in four that the average American family earns (median income -- $50,000), goes to health care! (average family health care spending -- $18,000).
- From 1999 to 2009, the inflation rate for health care in the US rose 60% faster than inflation in general.
There are many reasons for this crisis; the way doctors and hospitals are paid (per procedure, incentivizing more care), the costs the uninsured create when they get emergency room care everyone else has to pay for, obtuse billing systems that hide the true costs from the consumer. True as all these reasons are, they fail to recognize the core truth that lies at the heart of the health care cost crisis, the real reason we have not had the courage or wisdom to find a way to make hard choices... the reason why 'rationing' and 'rational' can feel so night-and-day different.
Comparing costs and benefits may be rational, but human risk perception is not. The way we judge danger, and figure out how to keep ourselves safe and alive, is not a purely fact-based, coldly objective process of cognitive analytical reason. It is a subconscious, instinctive, emotional process, the principal objective of which is not to serve some greater common good, but to keep each of us alive. The 'thinking' part of our brain may accept that the system can't afford everything for everybody, but the thinking part of our brain is only one part, and not the most influential part, of the way we figure out threats to our health and safety. Ultimately risk perception is a mix of the facts and how those facts feel, and the brain puts more emphasis on the feelings than the facts.
And so rationing, as much sense as it might make intellectually, upsets us because it threatens us. It literally viscerally threatens us. Never mind that the health care cost crisis threatens us too. Those threats -- to our ability to afford the comprehensive health insurance that would give us access to every medical option, to our family budgets, and to the prices of all the goods and services produced by businesses who pass along their cost of providing health benefits for workers -- don't seem as immediate, don't feel as real, don't feel as threatening, as it feels to have advanced inoperable melanoma and to be told that the government won't help you pay for a drug you can't afford, that could prolong your life.
So what will it be? Freedom of choice or rational rationing? Yervoy (and any drug or treatment that has even minimal benefit) for all, and the expense be damned? Or prioritizing coverage for care that yields the most health bang per buck, because otherwise, the cost of the health care system -- which we all have to pay one way or another -- will create bigger and bigger risks of its own? Until the debate about the cost of health care in America honestly confronts that choice -- and the realities of human risk perception that make it such a difficult choice -- we won't be on a path to true solutions.
Follow David Ropeik on Twitter: www.twitter.com/dropeik
Foul. Comparing the median of one amount with the mean of another is a no-no.
I don't know what the median medical spending is. The mean income is a bit over $60,000.
The basic point is correct: we spend a huge amount of money on our medical system, which could go to improve people's lives in any number of other ways. It's just the specific comparison that's off.
We have many other options to try first.
I had two family members with terminal lung cancer. One was told by the doctor, "you have 6 months if you do nothing, maybe 1 year if you go through chemo and radiation, but 6 months of your life will be hell." She chose to do nothing, and for 6 months lived a nearly normal life.
The other chose treatment, thinking he could "beat" the cancer, because he had already survived prostate cancer. He died after 6 months of hell, from complications of the chemotherapy, and leaving behind a large medical debt.
Everyone's decisions are different, but those decisions should be made with all the information available.
In the US way too may health care dollars are spent on the billing side versus the actual healthcare providers. You never see a nurse or practicing physician make 20 Million dollars plus perks a year but you do see HMO insurance or CEOs of drug companies make more then that and they never ever have to show up for one emergency
Some from overly medicated and some from none. So simple a problem, so complex for profit we make it.
So what will it be? Freedom of choice or rational rationing?
------
False Dichotomy.
This question only makes sense if you assume that the existence of a public medical system demands the abolishment of the private system. There is no lose of choice of any kind when a medical safety net is woven in the public domain to provide a certain level of minimum care. Private individuals retain all freedom of choice to seek care above the minimum.
For example. Let us say that we establish a social safety net for vision care. Everyone is entitled to an eye exam every year and a set of government-issue cheap frames.
This in no way prevents me from spending my own money on contacts, or on laser corrective surgery, or for more fashionable frames. I can still do all these things. It merely garuntees that I will always have access to glasses so that I can drive safely and my children will be able to see the black board.
It is a *minimum* standard of care. Not a *maximum*.
As for the article, I think it nails down very nicely some of the issues in health care. We have a schizophrenic approach to care; we want to address costs without impacting our sense of entitlement. Both the UK and Canada have tackled these issues head on. When the US tries to attempt the same thing, we hear cries of "death panels". Until our culture and expectations change regarding meaningful outcomes, health care will remain as it is today. For those who advocate single payer systems (and I do), understand that it comes with the loss of entitlement that so many treasure today.
When your health insurance attributes everything to pre-existing condition and refuses to pay for anything, you make rational decisions about what you want to pay for yourself. A drug that returns me to functioning/working is worth it to me. A drug that leaves me non-functional is not. Being stuck in bed 24/7 too drugged-up to even watch TV is not "living", and I personally refused to pay for that stuff once I knew what it would do to me (not "for me").
A more sensible form of rationing that makes decisions based on the most good for the largest number of people will include some rationing for those who are dependent on the amount of health care their insurance or assistance programs will cover. Those who have enough money won't find their ability to access the most expensive treatments impacted at all.
Then there would be enough left over to provide healthcare to all Americans.
Remember the doomsday scenario everyone is talking about has to do with the rate of inflation.
A good architecture, IT process can do that.
As long as we don't use the new UK IT system as a baseline.
But in reality, it all comes down to economics. Not just for the haves vs. the have nots. As the baby boomers age, we are going to have to make some very difficult decisions along the line. Medicare cannot take care of all of them without an enormous cash infusion...which isn't coming. It means making hard but objective decisions.....is this new drug REALLY worth the cost? Does this patient being considered for a transplant have a meaningful chance of surviving and living a high quality of life? Decisions will have to be made on an objective basis and not out of a sense of entitlement.
"...Any drug or treatment that has even minimal benefit for all, and the expense be damned? Or prioritizing coverage for care that yields the most health bang per buck"
can be found in requiring pharmcos to minimise the gap between these two options by minimising the cost of their drugs.
This expectation is not unrealistic when the alternative is that an equllay efficicaious competitors' drugs may be given preference instead. This will be all the more persuasive when Reform kicks in, creating so many new healthcare consumers.
The excuse that high costs are the result of research and development no longer applies. Nowadays, pharmacos spend more on advertising than they do on R&D - and health consumers should not be footing the bill for that.
Taken to the extreme as Pharma has done over the last decade it creates an anti-trust condition and they can really charge what the market will bear.
But this is a world-wide issue that must be solved because it won't be too long before an Indian or Chinese company discovers a drug and does the same thing.
Then both the US and UK will get to look around for a donor nation, like Africa does now for their Aids cocktails.
To clarify NICE's decision:
It considers the cost too high given questions that remain - at this time - about its efficacy.
So far, data supplied by Bristol-Myers Squibbs (Yervoy's maker) to NICE has come primarly from one trial only, and there have been no trials at all so far comparing its efficacy to other drugs. Furthermore, even when new drugs gain approval, NICE rarely rubber-stamps the maker's asking price - it negotiates (generally successfully) to get the best price possible for the NHS.
Additionally, where results remain questionable after extensive trials, a new drug may still gain NICE approval if it agrees to share the risk (i.e. cost), as has happened with other drugs.
In other words - as if often the case with NICE, this is in all likelihood the first of many steps and by no means a flat and final rejection as the article implies. There is also the Cancer Drugs Fund which helps patients get access to new drugs stuck in limbo.
The average American pays in around $200k and uses $300k, at $150k for a drug therapy, it really doesn't leave much room to cut.
They rock.
And in fact, for both private sector and Medicare in the states offer rebates based on the standard deviation from normal for the cost of treatment for all diseases.
Just like they do for cars.
Now lets attack something a little more challenging:
Now the government has predicted the future, because of that, investors can invest and innovators can innovate. Now the home medical office is a reality.
References
EHR http://en.wikipedia.org/wiki/Electronic_health_record
XML http://en.wikipedia.org/wiki/XML
XML schema http://en.wikipedia.org/wiki/XML_schema
XForms http://en.wikipedia.org/wiki/Xforms
web-services http://en.wikipedia.org/wiki/Web_service
IETM Class V http://en.wikipedia.org/wiki/IETM
DITA http://en.wikipedia.org/wiki/Darwin_Information_Typing_Architecture
A presentation by IBM using DITA
IBM http://dita.xml.org/sites/dita.xml.org/files/IDCMSBlue.pdf
Cloud Computing http://en.wikipedia.org/wiki/Cloud_computing
SaaS http://en.wikipedia.org/wiki/Software_as_a_service
An excellent article from a Brookings Institute Study from a medical standpoint http://www.brookings.edu/reports/2009/0901_btc.aspx