Rationing. There. I Said It.

Thirty percent of Medicare money, it's said, is spent in the last month (or is it six months?) of recipients' life. It shouldn't be surprising: people who die are generally sick. Sick people -- especially ones that die -- require more care than healthy people, or people who survive an illness. But it gets to the most thorny of issues when tackling health care costs. And it's a perfect example of why real reform is next to impossible: our politicians are too venal and stupid, special interests are too powerful, media are too superficial, the issue it too freighted with grayness, and the public is too easily distracted for there to be a meaningful discussion.

Notwithstanding the truths just enunciated, I have a few things to say. A proposal, too.

Absent having all the money in the world to spend on health care, I think it's fair to say that everyone is in favor of rationing. If all we had was a million bucks, would anyone choose to spend it on ten demented ninety year olds with advanced cancer and a 5% chance of recovery, instead of ten ten year olds with leukemia, with an 80% chance of recovery? So, like the old joke, we're not really arguing about rationing; we're haggling over details. Not to mention the fact that rationing, so loudly decried by the Foxoid among us as possible under "Obamacare" (whatever that is) is already happening with private insurance: of the dozens of plans offered by each of the twelve hundred insurers, how many cover all things for all people with all conditions under all circumstances? How many people get dropped after an illness, or refused in the first place? Wouldn't it be better to have such decisions made in a system open to public and medical input? (Along those lines, here's a pretty good, and humorous, commentary on the reality we currently face, still defended most arduously by the nay-sayers of the right-wing persuasion.)

End of life care presents us with some of the most difficult decisions we make, as families, as patients, as physicians. Likewise the related situation of "futile care." In neither case are there clear criteria to guide us. The exact same operation -- say, bowel resection for perforation -- would certainly be futile in that ninety year old (let's add some heart and kidney disease to make it easier), and entirely reasonable in a thirty year old, even if that person presented in septic shock. In the latter case I wouldn't hesitate for a second. In the former, I would try (and have, many times) to present for consideration the option of providing comfort care only. I won't psychoanalyze myself, but I hated doing operations wherein I felt there was virtually no hope of survival. (Need I mention that I made more money when I did operate than when I didn't? Yet I tried like hell not to, by presenting as candidly and openly as possible what I thought the situation was.) Not every surgeon would have done so.

I was always scrupulous about cost in my practice, from the little things to the big ones. Saving a few bucks on every case by not demanding different suture for every step when it made no difference: it adds up. So does thinking twice before heading down the road to futility. But it's neither universal, nor easy to know the signposts. Ought there to be some guidelines at the end of life, or should it be up to serendipity? I don't want to take judgment out of the equation; but not everyone has the same capacity for it. Which is part of the problem.

I can't back this up with any data, but when their grandma was dying, it seemed to be those who'd been with her the most who were the most able to let go. It was the out-of-town shirt-tail relative who blew in at the last minute who seemed to demand that "everything" be done. In those circumstances when it was insisted I go for the one/million shot, I've wondered if the same decision would be made were the family responsible for the cost.

So here's my proposal, in the context of the brouhaha over the idea of studying what works, and not paying for what doesn't: let's lay the money on the table. If a family wants to go ahead with an operation or other intervention, for which the odds of success are very long, or which is judged ineffective based on research (let's not get into details for now), here's the deal: if it works, Medicare (or is it Obamacare?) pays. If it fails, the family pays. Cash (credit card?) up front. Takers?

I see this health care "debate" as the quintessential test of our democracy. The need for reform is clear; the trajectory is, without doubt, toward disaster if changes aren't made. And yet, here we are, bogged down in disingenuous rhetoric, in overt efforts to stop it for purely political reasons. Trading amendments and concessions to various profiteers like bubble gum cards. Watering down the most serious proposals like potted plants. Media covering it lazily (all of them), sensationally (most of them), or entirely falsely and politically (you know who.) Advertisements and talking points designed to frighten, inflame, misinform. Citizens unwilling to think about it carefully. Faced with a crying need and a failed future that is not seriously in doubt, we seem unable to have serious debate, to argue on the merits, to legislate the sorts of changes that are needed. How can other countries have done it, and not us? And what does it say about our political system?

Can a nation of half-educated people, unable or unwilling critically to evaluate data; a media industry degenerated into selling soap over meaningful reporting -- and, worse, owned, operated, and scripted by people with overt political agendas; legislators elected for their dogmatism above all, the less serious the better; political parties more interested in power games than doing right -- can such a political system meet real and serious and undeniably needed challenges, or not? We'll know pretty soon. In fact, I'd say we already do.

F*ck 'Em

Or help 'em. Those, it seems, are the philosophical options in the funding of health care nowadays. In order to balance the budget, George Bush wants major cuts in Medicare and Medicaid. Primarily, his plan is to cut back on payments to hospitals and nursing homes. There is also on the table a pending cut of ten percent in reimbursements to physicians, but I'll not make this post about that except to say the obvious: there's only so much blood in that turnip. Somewhere there's a floor below which doctors can't and won't go. We're there, in my opinion. Care will become less available. But I'm out of the provider loop nowadays. So let's talk about recipients.

What do you do with people who can't, for whatever reason, afford medical care? You either bar the door, or you let them in. F*ck 'em, in other words, or help 'em. And if you help them, but don't pay hospitals enough to cover the costs, then in order to stay afloat, hospitals must shift the burden to those who do have coverage. Our politicians may be cool with deficit spending, but hospitals aren't, and can't be.

Controlling Medicare and Medicaid costs mainly by cutting reimbursement is, to use a sophisticated economic term, moronic. Unless the plan is to ration care by putting a bunch of hospitals out of business. I'm all for accountability and for the eliminating of waste in the system and for promoting best practices. But, as I've said previously, at some point this country will have to face the fundamental question: how much can we spend on health care, and how will we divvy it up? If we choose to ration care, or to have different levels of care for those that can pay and for those that can't, then let's just stand up and say it, rather than slither around it.

The problem with the (conservative) view that people ought to bear responsibility for their health care and retirement costs is that not everyone can. Many people count on Social Security -- anathema to so many on the right -- and retirees are expected by their former places of work to have Medicare to cover their medical needs at some point. It makes sense to me to index premiums and payouts based on a person's ability to pay. But the scattershot approach of continually lowering reimbursement to providers is chickenshit: it begs the question, and hides the real philosophical differences at work. Picking up corpses is cheaper than paying for care (if they smell bad, we could have illegal aliens do it). So would it be to send those who can't afford care to some place where they can do their damn duty and die. But if that's abhorrent, and if we choose to provide care, then cutting the payments for it simply shifts costs to businesses and rich people -- the very constituency Bush is trying to protect in choosing to pay less rather than to increase revenue. Isn't it cleaner and more transparent to adjust taxes to cover expenses (while doing everything possible to reduce costs)? Maybe the upcoming election will clarify where, as a country, we stand. F*ck 'em, or help 'em. Time to make the call.

Oh, and George's budget also has significant cuts in funding for medical research, as well as a 400 billion dollar deficit. So fuck us all.

More Solutions, Long Post

Free health care isn't free. The money has to come from somewhere; the question is how to get it into a bucket, and then how most effectively to get it back out, to where it's needed. People frame it in all sorts of ways, depending on their political persuasions. Andrew Sullivan says that in arguing for government to pay, liberals would have us all be permanent supplicants. Brilliant. And it fits nicely onto a bumper sticker. But it's fatuous. If the ultimate virtue is the taking of money out of one's own pocket and paying directly for one's health premiums, then probably less than 10% of Americans are virtuous. (No comment.) Premiums are paid by employers, by governments, but by only a few individuals themselves (I'm among them.) We're already supplicants. (Well, not me.) If there were universal coverage, taxes would go up somewhere, but premium expenses would go down. The money that goes into the bucket, in other words, would be mostly a wash. Left hand or right hand, it comes and goes. My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over. That would be good, by whatever method the money is taken from us, and by whichever agency it's given back in the form of health care. Package it with a name that makes you happy. Money comes from us one way or another, gets centralized somewhere, and returned in the form of plaster and penicillin. In what way does having insurers in the middle help that happen?

The always-thoughtful Eric worries: "The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly." He makes an important point, but, like my concern about monolithic control of reimbursement, it can be addressed (so says me, the non-politician, non-economist, non-systems-wonk) by having at the top panels of consumers and providers making reality-based (remember that bygone concept?) decisions. If such a structure were in place, given that we're now talking about a single entity instead of hundreds, it would be possible for providers and consumers actually to have control. This makes a strong argument for single-payor, as opposed to our current situation, wherein we're divided and conquered. How should such panels be constituted, by whom, with what feedback loop attached to the citizenry? I'm thinking, I'm thinking! But I'm guessing people much smarter than I could figure it out.

I haven't seen "Sicko" yet, but I've seen M. Moore's other movies, so I'm guessing that at its center, he has the problem right, and that in examples and solutions he's overplayed his hand with anecdotes and shot himself in the foot with hyperbole. Speaking of which, in a review of the film James Christopher of the London Times says, "What he hasn’t done is lie in a corridor all night at the Royal Free watching his severed toe disintegrate in a plastic cup of melted ice. I have." Interesting: in my opinion, universal health care has no business covering the re-implantation of toes. Fingers, yes (depending on which ones). Toes, unh-uh. If surgeons use big toes to replace thumbs, -- and they do, they do -- that they are otherwise dispensible, foot-wise, is spoken to. A thing to which it is spoken.

And that gets us to the nitty-gritty. The bucket isn't bottomless. We can decide how much it holds, but at some point we also have to decide for what kinds of care the contents will be doled out; unless we want to make it bottomless, which we could in theory, but won't and can't in fact. Keep the costs down, we all say, except (you know what's coming) when the care in question is for us or our loved ones. "Spend a little as possible on them, and as much as needed on me" is a plan, all right, but is hardly a workable one. (Less so in the minds of one political party than the other). But let me be clear (since I've given myself the soapbox): I'm OK with tiers in the system. Not tiers of joy, to be sure. But this is America; plus I've said in my previous post that I think payments to providers ought to reflect quality of work: if I'm asking for rewards for the quality of my work, I can't begrudge it elsewhere. It's not without moral unclarity (if health care is a right, it doesn't automatically follow that people should be barred from obtaining different levels thereof), but the idea that there might be a difference between basic coverage given to all, and that available to those willing and able to spend more is one I can accept. It's just the way it is: a system that is the same for everyone with no avenue for opting up won't fly, pragmatically, at this point in the US; but one that provided everything for everyone under all circumstances will bankrupt us, absolutely, eventually. Heck, we're heading there (bankruptcy) already, on more than one track.

It's either/or. Either we decide as a nation that we're happy spending whatever it takes on health care, or we address the issue of rationing (ok, let's call it "prioritizing.") Some countries do it openly: in England, on "the National" it was true at least at one time that, for example, a person of a certain age with a certain percentage of body burn got supportive care only: pain medication, comfort. Some do it de-facto and maybe even cynically: in Canada you have to wait a long time for certain procedures, which means some don't get them, even though it's not specifically proscribed. A few years back a British orthopedic surgeon responded to outcry over long waits for hip replacement by saying that the line wasn't as long as it looked, since some people die while waiting for the operation. Probably the hardest thing any health care worker does is deciding when further care is inappropriate. It goes on all the time; it's just not formalized. Somehow, sometime, on paper and in public, it needs to be. A comatose hundred-year-old in kidney failure doesn't get dialyzed. A ninety-five year old? Not him, either. Sixty? Sixty-five? OK, eighty-five? And if the idea is repulsive -- which it is -- and if it simply can't be addressed (certainly Congress never will), then let's just agree that the best we'll ever do is nibble at the edges. Which, to date, has pretty much meant nothing more than continually lowering reimbursement to doctors and hospitals. Turnip. Blood.

Outraged comments on posts such as this notwithstanding, people willing to work extremely hard under lots of stress to provide an excellent product have a natural inclination to expect some sort of commensurate reward. Certainly no doctor expects to get as much as a mid-level executive for Healthcom, or as much as a second-string second baseman. But something that reflects work and which doesn't continually drop would be nice. The price for the current approach has been, and will continue to be, burnout of the best, and the looking elsewhere than medicine by the sorts of people you'd like to see choosing it as a profession. The problem with us goddamn doctors is that we're also human beings. Tell me what you think a colon resection is worth, then stop lowering the amount every year. And if you won't let me charge more on my own because I do a better job (every other professional does), then show me a way you'll try to figure out if I'm better and slip me a little something. If not, don't expect everyone to keep striving. It doesn't work that way anywhere else; increasingly, it's not working that way in medicine, either. Which makes the next paragraph, probably, wishful thinking.

There's one thing to do before playing the rationing card. Doctors, as a group, have a hard time with it; but it's coming, and it needs to arrive. To the extent that it has arroven (yes, I know), so far it's pathetic. I refer to finding out what works, why some doctors get better results than others, why some can get the same results as others at half the cost. Determining, in other words, "best practices." Finding that out and putting in place methods to encourage the good and eliminate the bad. Care, that is. What we have so far, referred to by the much unloved acronym "P4P" -- which stands for "pay for performance" -- is, at best, silly; and at worst, counterproductive, because it's so stupid. An example of bureaucracy at its worst, the list of parameters seems to have been generated by a committee with little input from actual practitioners. Big surprise. I know medical quality is hard to quantify, to solidify into a checklist. But for surgeons, for example, the archetype is getting pre-op antibiotics into the patient no longer than an hour before surgery. Funny. In training, we were told to get it infused at least an hour ahead of time, so tissue levels could rise and equilibrate. Yeah, you can measure it and write it down. But what goes on much before that -- in terms of selecting and planning an operation -- and after that -- in terms of carrying it out and in providing post op care -- has volcanically more impact that the ticks of the antibiotic clock. Everyone knows that. Getting a handle on it is where the action is; but if it's possible at all, it'll take a hell of a lot of work. Thousands of records will need to be reviewed, outcomes compared, methods dissected. Necessarily, judgment will be called into question, egos will be threatened. Worse, errors in data collection and analysis will be made; conclusions may be wrong sometimes, or tainted. The various specialty societies and colleges will need to be at the helm, and it'll take time and will generate lots of heat (with good planning, maybe enough to reduce oil imports), but in my opinion it has to be done. All doctors and nurses know it: there are good ones, and better ones. And some bad ones. Crazy maybe, but I think most docs -- given the right incentives and handled in constructive ways -- will respond to information that allows them to do a better job, even if it means admitting that they may not have been in the past. Scream, yell, get pissed off, feel insulted. Then lie awake at night and think it over, look yourself in the mirror when you get up. And make some changes. Been there. Done that.

To the extent that people running for president are addressing health care at all, keeping the money-changers between consumers and providers seems to be a given, which strikes me as feckless and crazy. Why should a national health-plan include a layer which provides no care, is clearly dispensable, and which serves to suck huge amounts of money out of the system? It's like paying someone to put the key in your car before you start it.

So my thoughts distill to three things, needed in this order: a single-payor system that includes real and actual control at the top by providers and consumers; a no-holds-barred effort to find and encourage (enforce) best practices, which recognizes and rewards excellence; and, when all the money that's possible to save has been saved, the toughest of them all: prioritizing care; deciding which expenses make sense, and which don't -- rationing. (Alternative to number three: stop complaining about costs of health care.)

(I suppose it's not trivial that if the insurers were really to go away, there'd be lots of decent people without jobs. But that's hardly a reason to keep a useless system going. Maybe some of those displaced would be willing to do those jobs that, you know, Americans don't want to do. That way we could solve immigration, too.)