January 07, 2008
Paying for Hope for the Dying
Hard cases, it is often said, make bad law, and the same can be said for dying patients and health care reform.
This morning's Wall Street Journal looks at a case used by John Edwards on the campaign trail to illustrate the heartlessness of insurance companies. A 17-year-old girl died of leukemia shortly after being denied a liver transplant by Cigna Corp. Though the insurer reversed its decision on the day she died, its excuse for denying the treatment was that there was no data to suggest it would improve her chances of survival. As the story pointed out, the transplant wasn't curative. It had a 65 percent chance of extending her life another six months.
This story is very similar to the case that Michael Moore used in his film, "Sicko." In the film, an African-American, dying of cancer, was denied an experimental treatment.
Any system of universal health coverage will ultimately require reining in rising health care costs to be affordable. Affordability requires moving toward some form of evidence-based medicine, where medical interventions only get paid for if they are based on scientifically validated medical evidence.
As Shannon Brownlee's new book "Overtreated" points out, an estimated 30 percent of all U.S. health expenditures are wasted: physicians, hospitals, and drug and device companies padding their bottom lines by selling and administering unnecessary or ineffective tests, drugs and procedures. That's far more waste than the 15 percent that insurance companies skim off the top for administration and profit, or pad their own bottom lines by denying people necessary care.
But trying explaining that to the public in a 30-second sound bite. And can you imagine what the horse race reporters and theater reviewers who cover politics would do to a candidate who stood on a podium with his or her arm draped around a 57-year-old man who just went through an unnecessary colonoscopy because he was given an inaccurate stool test, or a 62-year-old woman whose cholesterol level and heart attack risk profile makes her prescription for Lipitor completely inappropriate?
Moving toward evidence-based medicine will require creating and constantly updating a trusted base of evidence that can be used by paying agencies, whether in the public or private sectors. A new institute to create that body of evidence is high on many candidates' agendas. But none of them are willing to tell the public that, in some cases, evidence-based medicine means denying payment for heroic but probably useless interventions.
The lesson for health care reformers in the story is that serious reform will make official what already exists: the nation's two-tier health care system. If the family brought on stage by Edwards was rich, there would have been no question about her ability to get a liver transplant. They would have paid for it themselves. If the evidence suggests they are probably wasting their money, well, it's their money.
A universal system must ensure that everyone gets a high standard of care, and that all the treatments, even for life-threatening conditions, are made universally available as long as they have been proven effective. But should a universal system also have a cost-effectiveness standard, like they do in every other advanced industrial nation? That ultimately leads to denying care to patients when the benefits -- perhaps a few months of extra life -- come at a very high a price, and what someone -- the government, the insurance companies, an outside panel representing all stakeholders -- has determined is too high a price.
As the Baby Boom heads into its declining years, this is a debate that the nation cannot avoid. It's also a debate that will only be harder to have after the election because of what got said on the campaign trail.
Posted by gooznews at January 7, 2008 07:57 AM
It has become a fact that the second most important issue of the 2008 Presidential election is universal health care. Or should I say health care, itself.
Yesterday, at a rally in New Hampshire John Edwards blatantly used the Natalie Sarkisyan’s family to underscore his passion for universal health care. No one can say our system isn’t broken. The fact is, it is not only broken, it is a disgrace.
Recently in my city's local newspaper, I read a side by side article. One was about the influx of Burmese into our city and how they are taken to all the entitlement programs to get signed up when they hit our streets. The sponsor of these immigrants was sad that Americans didn't reach out to them-you know -show them the sights of the city--the zoo- the mall, and the local parks.
The other article was about a lady who had worked for 35 years in my city as a waitress, she had raised two children working her butt off. Then, she fell ill and was unable to work, she lost her home, car, and was now living in a trailer provided by an ex-husband. She was terrified of what tomorrow would bring and did not know if she would have food each day.
Read this "joke" that clarifies this situation.
A Somali arrives in Minneapolis as a new immigrant to the United States He stops the first person he sees walking down the street and says, "Thank you Mr. American for letting me in this country, giving me housing, food stamps, free medical care, and free education!"
The passerby says, "You are mistaken, I am Mexican." The man goes on and encounters another passerby." Thank you for having such a beautiful country here in America !" The person says, "I not American, I Vietnamese."
The new arrival walks further, and the next person he sees he stops, shakes his hand and says, "Thank you for the wonderful America !" That person puts up his hand and says, "I am from Middle East , I am not American!" He finally sees a nice lady and asks, "Are you an American?"
She says, "No, I am from Africa !" Puzzled, he asks her, "Where are all the Americans?" The African lady checks her watch and says ... "Probably at work.
And I just want to say the following. Thank you, Mr. America for giving all the tax dollars these wonderful Americans have paid through the tax system to those who have never worked here, and have not contributed to America. Thank you, Mr. America!
Posted by: A Smythe at January 7, 2008 08:16 AMGooz is right, as is often the case. This liver transplant issue, which I also chew on in a blog at www.cfah.org raises the real question of reform which is how and when we'll say "no." As Edwards tells the story the intuitive and obvious answer is yet. Obviously we all think that rich employers and insurance firms should unquestionably pay for such procedures. whether we'll be equally generous when the money comes out of our own pockets is an open question -- a key one that the political debate intently ignores, for obvious reasons.
Posted by: jim jaffe at January 12, 2008 03:07 PMwrong question.
the question should be how can we maximize health - not how do we access health care.
Huckleberry is almost asking this question although he only deals with the "personal responsibility" part - not the corporate foisting of health externalities from marketing bad foods to children to tobacco to pollution of workers & the environment.
But as to the latter I am with Edwards. The question here is WHO decides & HOW is the decision made.
These should not be market decisions they are public policy decisions that should be made by the public through their representatives.
Posted by: David Egilman at January 12, 2008 04:35 PMEvidence-driven care sounds wonderful, and in fact cold-blooded actuarial prediction trumps most--not all, but most--docs' analyses. However.
However, this leaves another awkward question: who decides what to investigate and what evidence to gather?
Now we get some circularity between what care is likely to be most profitable to some company and what ills are advertised most pitifully, so that finding treatments becomes a high priority.
Concrete example: hyaluronic acid (spelling suspect) is a joint lubricant, among other things. Squirt some into a creaky, arthritic joint, and it may work more smoothly until the stuff is absorbed. Or just maybe it stimulates the body to
get back to producing its own in the quantity needed for lubricating the joint the way it needs to. FDA-approved not long ago for restoring creaky knees. Why knees? Bigger audience than other joints. Want it for your finger or back, and unless you can convince an investigator to fit you into one of the ongoing studies, your HMO/PPO won't pay for it. Medical boards are fine with your own doc squirting some in, if he's pretty sure it's just a matter of time before it's approved in your particular aching joint, though you'll have to manage payment on your own.