Monthly Archives: November 2012

Rationing health care in America

Joe Klein wrote in the June 11 2012 issue of Time Magazine about the different kind of advice he received from his parents’ care team. Klein said Geisinger Health System’s medical staff did not recommend expensive end-of-life procedures for his elderly parents in rapidly declining health. Instead, the care team helped Klein through the difficult decisions in helping his parents die peacefully.

I attended a most memorable health care seminar in 1982, soon after joining my hospital’s management team. The speaker, an ethicist/physician, warned us severely, “If you are dying, do NOT go to the hospital. They cannot let you die in peace. In fact, they will violate you, stick you, pound you, shock you to try and keep you alive. They aren’t trying to let you die — they are trying to keep you alive. Die anywhere, but don’t go to the hospital if you are dying.” More tests, more procedures, more billing, better living?

This is an emotional topic for most people. A lot of folks are worried about someone pulling the plug “too early”. You can read comments which raise concern about losing control over deciding for ourselves. And, as Joe Klein so elegantly wrote, he was grateful for health professionals helping him make the toughest decisions in his lifetime about his parents.

Our country’s health care delivery problem is partly about rationing health care, to ensure affordability and access for everyone. And it is about controlling the rate of cost increase. Health care reform cannot succeed just by extending access to care to everyone. In fact, our nation cannot afford to provide as much as possible for as long as possible to as many as possible without also controlling the costs of care delivery.

We dined recently at a neighbor’s house. He is older, from the States, and says he is beleaguered by numerous health problems. The other guests were young escapees from careers as health care providers Canada. We were comparing delivery systems of health care between Canada and the States, and our Old Friend complained he is just worried about “death panels” (I hate to even use the term, but he did.) Old Friend asserted death panels are legislated and might rule out further spending for his continuing health care. He even “knew” the page number but didn’t remember it last night.

So I hit the search engine to get what I could on this wrongful legacy from Sarah Palin. Bottom line, I did find a well-argued dismissal ( of the notion of a death panel determining whether Old Friend could, or not, receive a procedure. Then I followed the link to the Affordable Care Act’s relevant pages on the Independent Medicare Advisory Panel and reread them.

Yes, the “Act” intends to “reduce the per capita rate of growth in Medicare spending” (SEC. 3403. (a) (1) SEC. 1899A. (a) (b) page 489) even as it extends coverage to all Americans. We, all having been raised to prudently spend and to conserve, wouldn’t think of ignoring the relationship of cost and outcome with our own dollars. Efficacy of care delivery vis-à-vis outcomes makes really good sense. Our auto or home insurers dictate the cost level to which an adverse event is reimbursable — if they didn’t then we could none of us afford said insurance. Why should health care costs be so different?

We are a country full of the smartest, best-looking, nicest people in the world, we have the best medical care money can buy, and we deserve it all. We paid for it, didn’t we? Listen to what Thomas A Shannon, PhD, member of Geisinger’s Bioethics Review and Advisory Committee, writes about this notion:

“The discussion of rationing must occur within a cultural context and I wish to identify several issues I think important in current American health care debates. Generally speaking, we tend to think that if something is good, more is better and as much as possible must be best. We also typically assume that no barrel has a bottom — all resources are infinitely renewable. We are quite certain that our medical system is the best in the world. And because our system is the best in the world, we then assume that our medical system ought to be able to cure anything. And because we can cure anything and because we have already prepaid for health care through insurance, we naturally assume that we are entitled to as much as possible for as long as possible. And since I have prepaid, very definitely any sort of queuing up for services is totally un-American.”
[from July 2007 Geisinger Bioethics Notes,

They can’t ration an infinitely renewable resource to which I have every right, can they? Sure they can! Dr Shannon and others very sensibly explain how care is and always has been rationed in some ways. Dr Shannon labels some of this as “indirect rationing”, as in scheduling, location, costs of services, or required paperwork to obtain services. Many of us have experienced direct rationing, according to Dr. Shannon, through HMO or other reimbursement capitation models whereby we are told what drugs or procedures or therapies our insurance will and will not, allow.

There is seemingly no end to the rapacious appetites for profits of big pharma, medical imaging, home health, and medical tort. A friend’s surgeon recently commented, “I’m paying $200,000 per year in malpractice insurance even though I’ve NEVER had a claim against me.” How much of the increase in health care cost is attributable to our country’s medical tort system? The rate of increase in health care costs is, according to some policy centers, driven 40 to 50 percent by new or increased use of medical equipment. Do you suppose those cost increases are increasing our citizens’ health as much as increasing profits? Could fee-for-service reimbursement plans drive increased utilization of services?

Smart policy dictates our government sustain a system for provision of health care through efforts to “reduce the per capita rate of growth in Medicare spending”. Smarter spending, better health information systems, rewarding more the successful care providers, not paying for faulty work, and discouraging performance of ineffective tests and procedures can all help reduce rampant cost increases. Somebody or some body must take on the tough job of making the right decisions. The “Act” charges the Independent Medical Advisory Panel with this responsibility.