Extraordinary Care
Earlier this week, Elizabeth Warren returned to the compelling story of a child named Matthew who was born with a heart defect, is in fragile condition, and will need a series of heart surgeries throughout his life. He has already passed the $2 million lifetime cap on his insurance. His father’s union negotiated with the insurer to raise the cap, but Matthew will need more help. His parents were hoping that Nevada might make funds available, but recently, the state said “no.”
Who should help Matthew? And should there be any limit on how much is spent on a single individual?
My answer is that this is a question of medical ethics that needs to be addressed, case by case, by a panel of physicians. And yes, in a world of finite resources, there will always be limits: we have to ask, “What value are we getting for our health care dollars?”
First, it makes no sense to leave questions about how much to spend up to for-profit insurers. Under U.S. law, a for-profit corporation's first responsibility is to its shareholders. I'm not saying that this is wrong --or that it is right--just that this is how capitalism works.
Thus, an insurer cannot say “there is no limit on how much we will reimburse to care for Matthew over his lifetime--and we are prepared to write a blank check for an unlimited number of Matthews.” With a little bad luck (finding too many Matthews in its pool of patients) a company could wind up bankrupt.
In an earlier post, Elizabeth Warren quoted Jon Cohn, author of “Sick!” who observes that the current insurance system isn’t well designed to handle the costs of extraordinary cases like Matthew’s. “One employer or group of employers isn’t well-suited to a multi-million dollar outlay for the care of a single child. So they put caps in the insurance coverage, which protects them and which the employees never really see—until they need extraordinary medical care.
“Private insurance isn’t enough for Matthew or for any of us,” Warren continued. “We need a bigger pool for spreading the risks—and the costs—of these extraordinary medical events. That’s where government can be most helpful, putting us all in the same risk pool for extraordinary care. Without that step, even the tens of millions of Americans with health insurance will remain financially vulnerable to an extraordinary medical crisis."
Warren is right that a national pool would be better able to absorb the cost of extraordinary cases—and this is a good argument for national health insurance. But, even with national insurance, we cannot afford to provide unlimited care for an unlimited number of patients without asking, what are we getting for our healthcare dollars? Are we simply extending a life of pain without hope? With advances in medical technology we can keep people “alive” for years while prolonging suffering.
Keep in mind that, while spending over 16% of GDP on healthcare, we are fast approaching a point (about 20% of GDP) when we will have to cut spending on education, the environment, the arts etc. to keep up with healthcare inflation.
This is why judgments about how much to spend on Mathew—or how much to lay out for end-of-life care for another patient-- should be medical decisions, made by a hospital’s “ethics committee” (a committee composed of doctors and medical ethicists)-- not financial decisions made by a for-profit insurer.
An ethics committee arrives at its judgments based on a combination of medical science (what quality of life can this patient expect if he or she survives? how long is that life likely to last?) and the patient's and family's preferences.
Palliative care specialists need to counsel the family and help them sort out their hopes and fears. With further treatment, is Matthew likely to live months or years? Will he be in pain? If we put your grandmother on a machine to help her breathe, will she ever be able to come off that machine? If a family is dissatisfied with the committee’s decision, it can appeal to a court.
Under national health care, a hospital that made a medical decision to provide extraordinary care would be reimbursed for whatever it cost to provide the care—though the hospital and doctors probably shouldn't make more than a very modest profit on extraordinary care. Otherwise, they might be tempted to over-treat.
Finally, returning to our current for-profit health care system, I’d stress that for-profit insurers just don't possess the moral or political standing to make these ethical decisions for us.
Moreover, the best for-profit insurers don't feel comfortable making such judgments. In the late 1990s, Alan Hoops, then CEO of PacifiCare told The Los Angeles Times: “We’re in the business of constantly passing judgment on the societal value of a given [medical] protocol. We are making very difficult decisions on questions that, frankly, have no right answer.” As medical technologies advance at warp speed, the question of what is “medically necessary” is taking us into unknown territory.
“How much reconstructive surgery is truly needed for children with a severe facial disfigurement?” The LA Times asked. “Surgeons could restore normal functions or should they do more elaborate and more costly work that would dramatically improve patients’ lives?
Here, my own opinion is that the child should receive the very best, and most complete reconstructive surgery possible--- so that he can have a happy as well as a long, healthy life. I’d add that, too often, children like these are very poor. Often their mothers did not receive proper pre-natal care, or the child was hurt in a fire. It can be harder for many of us to identify with these children and their famlies. Yet they deserve as much care as the most beautiful middle-class child.
I'd been hoping that Maggie would post about Elizabeth Warren's case, and I think she hit exactly the right balance. She suggests it shows why critical decisions on patient care should not be left to the market but nonetheless will have to be faced. I can't argue with that.
I've been assigned as editor for a future bioethics text. I can see how a case like Matthew's would spur considerable, fruitful discussion under more than one heading, including both "futility" and "allocating scarce resources." There wouldn't be one answer, and I'd hate to see it thus become too easy an argument for any insurance policy standard, public or otherwise.
John
http://www.haberarts.com/
June 19, 2007 12:47 PM | Reply | Permalink
The average share of national income per persome time his or her lifetime is between 2 and 3 million dollars. Clearly, we should not be spending that much on every person.
Thus, we can justify multi-million spending in rather rare cases, especially if we can extend the life (or quality of life) of an individual for decades to come.
There is a conundrum what to do when the diagnosis and/or the treatment is highly uncertain. I would classify those cases as experimental and subject to random choices -- so over time they would provide a relatively unbiased evidence for and against various medical options.
June 19, 2007 2:41 PM | Reply | Permalink
To my view, your exposition is based on a false assumption. Although resources are finite by definition, there are enough resources to deal with most severe cases. Of course, if CEOs have to make $100 million a year, there will be very little left for sick people.
Mathew is actually a rather common case. Although I don't support this statement by statistics, I have heard of a larger than we would like to hear about number of kids with severe heart problems that require numerous surgeries and treatment.
We do have enough to deal with Mathews and alike. We don't have the resources now because we pretend not to have them and because those resources are spent on buying larger homes, larger pools and larger what have you.
June 19, 2007 3:05 PM | Reply | Permalink
Sorry, the "we are running out of funds" argument doesn't hold up. The US spends 50% of the discretionary federal budget on militarism. If we are short of funds for social insurance programs then let's not ignore the 800lb gorilla.
Here's a nice graphic which shows where the money goes:
The Federal Pie Chart
The US spends as much on militarism as the rest of the world combined. How does the EU survive without spending so much money? Where does it get its resources from? Simple, it buys them on the open market. The funds not spent on militarism are used for social programs instead. The military-industrial-congressional complex has skewed our national priorities and is now making us less able to compete in the world. Much leading edge science research is being done elsewhere, for example.
We can blow up any spot on the earth we wish, but we can't run the countries we invade. The sooner we learn this the better...
--- Policies not Politics
Daily Landscape
June 19, 2007 3:27 PM | Reply | Permalink
Having worked for a financial company where one of the divsions reporting to me was healthcare, I am intimately familiar with the dilemma Maggie and Elizabeth are wrestling with. First of all I would echo what the Pacificare CEO said - insurance companies and HMO's have no business making these kinds of decisions. Yet, today in subtle ways they still do.
For example, most expensive cases ultimately involve costly and/or experimental drugs. If the insurance company will not cover the drug because it is experimental then the whole course of expensive treatment is likely to change. I can assure you that a decision on covering experimental drugs is made with an eye toward what kind of expenses might follow. For example, if drugs costing $200,000/year are approved(there are such drugs) and the patient lives and required another $2 million in surgical procedures and hospitalization, the drug decision might go negative. These kind of discussions happen in hushed tones in conference rooms all the time.
One of the things I tried to get our lobbyists in DC interested in was a Federal reinsurance program for all claims in excess of $50,000/year/individual(or $100,000). All insurance companies/HMO's would be required to participate and pay a reinsurance premium to this quasi-governmental agency ( like the PBGC) This would get insurance companies out of the business of making de facto life and death decisions. Those decisions would now rest with local and regional boards of physicians/ethicists outside the confine of the local hospital(which also has a potential conflict of interest).
Back in the 1990's most Group Insurance contracts had ultimited major medical maximums. As expensive cases proliferated that nice benefit was withdrawn. During my tenure in charge, the most expensive case was a $9.7 million premature baby with numerous medical conditions. It was heartbreaking to see what that baby and her parents had to endure all to no avail after a three year struggle.
In short, I would like my resinsurance idea to be resurrected (in 1995 when I proposed it, no politician would touch healthcare legislation with a 10 foot pole) and the medical ethicist boards to be developed. We need to seriously address healthcare costs. Premature births, life threatening cancers and end of life care are prime areas to mine. I think the estimate of 16% of GNP for healthcare is too low - that's only about $2 trillion. I've sure seen numbers higher than that and I'm figuring it's closer to 18% now. Maggie is right if we don't slow down this run away train, it will quickly eat up 20% of GNP. What happens a few decades after that when it reaches 33% of GNP. We'll have one worker being productive, one worker sick and one worker taking care of the sicky. Just think of where the US will be then in terms of our standard of living.
June 19, 2007 3:47 PM | Reply | Permalink
Thank you for your comments.
First, I really like Jdledell's idea that we need local or regional boards of physicians/medical ethicists that have no affiliation with a particular hospital to make these decisions.(This is much better than my proposal that the decisions be made by a hospital's ethics' commitee--Jdeldell's avoids the inevitable conflict of interest.)
Secondly, as to whether we can afford to spend an unlimited amount of money on healthcare for each and every individual who might conceivably be eligible for unlimited care. . ..
Let me emphasize: This is not just about money: overtreatment adds to human suffering. Too often, both preemies and the elderly are kept alive in ways that you and I would not want to be kept alive. I have complete sympathy for the families who do not want to let go. This is why they need counseling, from palliative care specialists, to help them sort out whether the care is or isn't doing the patient more harm than good. (Let me be clear: In Matthew's case, I have no idea. I don't know enough about about his condition, and even if I did, I'm not a physician.)
In terms of the money: too often, someone (a drug company, a device or medical-equipment maker, a hospital or even a doctor) profits from this over-treatment. This is why, in our profit-driven healthcare system, too many people are overtreated.
And while I personally agree that we spend too much on defense and militarism, our current spending has much to do with both the Iraq war and our somewhat hysterical response to terrorism. (I really don't think the people who make me take my shoes off in an airport are making me any safer).
Our spending on the war in Iraq is, one hopes, a one-time multi-year expense. (Unless you assume that once we eventually get out of Iraq, we are going to be foolish enough to invade another country every few years or so. Vietnam taught us a lesson--that we remembered for about 20 years..I'm guessing that Iraq will also teach us a lesson that we will remember for 20-odd years.)
By contrast, our spending on healthcare is not a one-time expense. It is a year-in-year- out expense, and the national tab has been rising by 7-8% a year-- roughy 2 to 3 times as much as regular inflation, and 2 to 3 times as much as current growth of GDP.
As a friend points out, "If we keep this up, we won't have money for education, the arts, the environment, or anything else. We'll all just be
operating on each other."
Finally-- re: CEO salaries, I totally agree, they are scandalous. I've written about this in
my first book (Bull! A History of the Boom . .)
But if you add up the CEO salaries of all of the Fortune 500 companies in the coutry you'll find it is just a drop in the bucket compared to the $2.3 trillion that we are spendng on healthcare.
And there is now a consensus among health care policy experts that about 1/3 of that $2.3 trillion (or over $700 million) is spent, every year, on care that is ineffective, unproven, sometimes unwanted, and usually over-priced.
Meanwhile, the people enduring that overtreatment suffer.
June 19, 2007 5:10 PM | Reply | Permalink
Maggie - One word of caution. If you go the route of the ouside panels on these cases, you also have to do something about the money. If the Insurance company is still on the hook for a couple million dollars they will fight the panel's rulings tooth and nail and make life miserable for all. So you can go with a government single payer approach to avoid the money angle or if you allow private insurance you've got to get them out of the financial implications on their profits. That is what is behind my government reinsurance plan.
June 19, 2007 6:24 PM | Reply | Permalink
jdledell--
I agree completely.
I am assuming that we will have national health insurance as an alternative to private insurance--hopefuly by the end of the next
administration's first term.
As a (distant second) alternative, I can imagine people having have a choice between public national insurance and regulated for-profit insurance. (By "regulated" I mean no cherry-picking. For-profit insurers would have to insure people with prior conditions at the same price as healthy patients, and they would have to provide comprehensive insurance to everyone.
In other words, for-profit insurers would have to compete on a level playing field with public national health insurance like Medicare.
If that doesn't happen, then we need at least to have what you suggest: gov't reinsurance that covers extraordinary cases.
But that will be much more expensive for taxpayers because we won't have everyone (the young and healthy, the young and unlucky and the older and not so healthy) in the same pool.. .
June 19, 2007 7:05 PM | Reply | Permalink
In the US we tend to believe that markets can bring us the best possible solution in almost all situations. I have reservations about how often this is the truth. As regards health care, for the last 30 years I have been hearing the market will deliver "the solution" without any sign so far that it can or will.
When one insures a house, the building and contents can be valued and is finite. One's premium is proportional to this and the appraised risk. The house burns down and, although there is some emotional trauma, the house and contents are replaced. Life goes on relatively unchanged.
This all changes with healthcare. We cannot, nor do we want to, appraise each individual on their risk. We do set limits of coverage expenditure.
So we run into these very uncomfortable cases where no one actually wants to make the decision "no more".
However, even before limits are reached there is a tension. The insured are willing -- if they have the copay -- to spend as much of the insurers money as to secure the best of all possible outcomes for themselves. The insurers have no real interest in the outcome, only in limiting the expenditure as much as possible.
A drug company with a medication that is either unique in its efficacy or significantly better than any competitor is in the position of a monopoly supplier. (By the way, European drug companies have remained world-competitive despite being rooted in national health care countries.) New medical procedures start at one or two top class research or teaching hospitals and percolate downwards over time. Access, if this applies to a fairly widespread condition, is available only to the fortunate few, which will mean, mostly, the rich and well insured.
Meanwhile, we have all the emotions of life, death and loss, suffering and quality of life, and relative inaccessibility for those with fewer resources (insurance, income, wealth), the risks of bankrupcy and a life changed.
The patient rarely has the knowledge or time to make informed choices. In an emergency no time or choice. They expect the doctor (or other practitioner) to act as an advisor and advocate when the practitioner is a captive of the insurer.
Healthcare is not a normal market with market stimuli.
I've gone on long enough, but it is time for the US to think beyond its delusional box. There are approximately 26 other countries, mostly with better overall health care outcomes for their populations at considerably less expense, for us to have a look at and come up with the better health care mousetrap. Soon!
June 19, 2007 11:27 PM | Reply | Permalink
This Ms. Mahar, IMO, is all about a system that lacks justice. This is an extremely important issue that we as a society are failing to address properly, thanks for raising into plain sight by bringing us Matthew's example.
June 20, 2007 2:54 AM | Reply | Permalink
"But that will be much more expensive for taxpayers because we won't have everyone (the young and healthy, the young and unlucky and the older and not so healthy) in the same pool"
Maggie - Because the reinsurance is mandatory for ALL private insurance, the government reinsurance pool will include ALL participants, young, old, healthy and sick. This means the risk is spread completely and the cost is as low as possible.
Given my background, it may surprise you that I am in favor of a single payer systerm. However, I am politically sensitive to the fact the the US may first need to take a private insurance overhaul to the healthcare crisis before we get to the ultimate solution. If that is the case, take the reinsurance route.
June 20, 2007 3:34 AM | Reply | Permalink
By contrast, our spending on healthcare is not a one-time expense.
I just don't understand where this conclusion comes from! Military equipment must be replaced, veterans' benefits must be paid, the US has military bases in 100+ countries, the "homeland security" budget is being ramped up, etc..., etc...
It seems to me that both the military and health care are a drag on GDP.
To boldly go...
June 20, 2007 6:49 AM | Reply | Permalink
Markets and regulatory mechanisms aside, it'll be necessary to shape a structure such that the review mechanisms responsible for setting guidelines for appropriate care and physicians who try to carry them out are immune from excessive risk in delivery or nondelivery of care while patients in turn have some rights to seek legal protection or redress in such matters. It'll be interesting to see the details of how that can best play out. Makes me glad I don't have to draft the legislation myself.
John
http://www.haberarts.com/
June 20, 2007 8:12 AM | Reply | Permalink
“What value are we getting for our health care dollars?”
Value is the wrong word. Value implies Allocation, rock, scissors, paper games not expense driven pricing. There are mazes of games between the providers, drug companies, equipment providers, and implant device makers.
Lets cut to the chase. What insurance companies will pay more for is allocated the most cost as to reap the most income in health care. Are the insurance company investments in these winners in the health care system?
An example is the price fixed for that new lens for the eye depends on the time it saves the surgeon and the cost of the all the costs of the procedure it replaces? Never mind before there were only a thousand performed in the world before and now there are a million a year performed.
Drug prices, the companies say we pay for the research for the world. That is we subsidize the single payer government paid health of the world as our grand parents die because of the expense of drugs for these countries that can afford to pay their share.
Is that true? Or is it the prices of drugs for the uninsured are set high to put a mark to begin negotiations for the drug companies and insurance companies to negotiate from. Do Americans die for lack of medicines so they can reap more money?
These settlements are in private contracts they say and the prices cannot be told as to what your insurance company pays. The difference is rebated back to the insurance company from the drug company after the cost is run thought the books of the insurance companies. I have been told that we can't look at these "private" contracts.
With hospital bills discounted to 20 to 30 percent with physical real buildings, people, and other real costs not value pricing, can you imagine the kickback money the insurance companies get for the drug discounts?
How are these rebates of expenses paid treated? Does it reduce the "costs" for the insurance companies? Is it treated as earned income (they themselves negotiated it) and not used to offset the costs charged to the policyholder? Do we know? Do our elected representatives, the politicians, care what happens to us?
The medical professionals have been in the pot and heated to a boil and can't see around them. We tell them to do this and they are not compliant, don't take medicine, don't do exercises, don't do as I instruct them to do. All in the 7.5 minutes the physician has ALOCATED on average to treat the patient. When asking for more detailed instructions I have been told, “we used to have a detailed pamphlet of instructions, but it raised more questions and took more time to answer the questions it raised.”
I am not saying all are this way, but what I am saying is that the majority goes along with the way the health system today without fighting back. The system could not continue without them.
You know the insurance companies advertise that what they command you, the doctor, to deliver is the best health care in the world. It helps that the world's actions and information is not allowed into America for us to compare.
What a system! The processes are killing Americans but they think it is the best of everything when it is the hype of myth information for profits.
The profiteers, keep talking about high and lofty ideas, ignore real facts and forget the dying. I think it is time to blow our cremated ashes around the corridors of power. It may be the only blowback that will get their attention!
-----------------------------------------------
Today, are we searching for I deals or Ideals?
-Thinking
June 20, 2007 8:15 AM | Reply | Permalink
I realize the focus is on health care and I keep bring up militarism, but I'm afraid it is necessary...
If you examine the federal budget over the past several decades you will find it hard to determine which party was in the majority at any given time.
Here's a chart going back to 1962 from the CBO (pdf)
There have been slight changes in spending levels, for example during the Clinton era, but in general things tend to stay pretty much the same from year to year.
Our focus on militarism has not only distorted the health issue, but education and support for science and technology as well. Rather than restructure our economy to be more sustainable and less dependent on cheap foreign raw materials and finished goods we assume we will be able to bludgeon others into providing what we need at favorable prices.
This policy has now started to fail. The US is getting poorer and our standard of living is slipping. The use of aggregate figures helps hide this, but those in the middle and lower classes can see the effects for themselves. Health care won't be the only sector to suffer.
--- Policies not Politics
Daily Landscape
June 20, 2007 8:19 AM | Reply | Permalink
Maggie,
On the independent panel thing, let me just say a few things from an recent very up-close-and-personal extensive "end of life" experience that was mostly in the I.C.U. but also in Long Term Acute Care (which was very painful and stressful for the whole family and for that reason I do not wish to detail but to say that it was not a classic end-stage cancer thing but someone who managed severe chronic illness for many years quite well and bounced back from crises often.) I often saw and heard the experiences of many other families there and I am including them here:
It would be an excercise in futility if a hospital ethics board were making these decisions while for-profit is still involved. (And I feel that any "non-profit" hospital still has profit motive in a system that is for-profit--they have to maintain certain things to stay alive.) The immediate thoughts of family members involved run to "what is the financial incentive for him/her to say this/to want this?" This is especially true because of so many specialist doctors (and hospital social workers for that matter) having terrible communications skills and terrible bedside manners. An independent board would be soooo welcome to most families, I assure you.
Do you know the scene in "Lorenzo's Oil" where the mother fires the private nurse because the nurse is sure that Lorenzo is a vegetable and resents reading to him? That is the kind of thing you are dealing with here. All involved parties can never be seen as making a "fair" determination by all sides.
As evidence of how easy it is currently to "game" a hospital's "ethics" decisions, I give you the recent example of Dr. Michael E. DeBakey's heart surgery at 97.
If you really want to get seriously into this topic, I suggest getting permission to spend a month in a typical I.C.U. talking to the families there and hearing what they are experiencing. It's not what most people would expect from reading those obituaries that say "thanks to all the doctors and nurses over at...." There is actually a lot of moral confusion going on and I truly feel sorry for those patients who are too sick to speak for themselves and have no strong family advocates.
Edit to add: one thing I learned is that most "living wills" are worthless in helping make decisions about care in most cases. They cannot possibly foresee problems and choices that happen. You usually need an "after the fact" ruling, there is no way of knowing from a living will whether the very sick patient wants the more radical procedure to stop the internal bleeding that just started or the simpler one. The questions that arise from treating serious illness these days simply cannot be addressed before they happen.
June 20, 2007 8:36 AM | Reply | Permalink
ArtA is surely right about the complex feelings of families and the limits of a living will. My father had a living will when he went in for a heart operation. He remained in an ICU for the subsequent nine months until his death.
Technically, the temporary kidney failure that sometimes follows such surgery led to additional complications. Fluid buildup in critical organs obliged a breathing tube to do most of the work from then on and an IV to take care of all nutrition. It also necessitated spot invasive procedures to help, either to drain or to remove consequent damaged tissue around the lungs. Electrolyte imbalances affected mental functioning. All this put greater pressure on organ function that ended up making dialysis necessary again, beginning the cycle of problems again to a more dangerous degree.
In short, I was seeing futility and slow decline but no obvious decision point. The hospital went slowly themselves from optimistic to wanting him out of there for terminal care, which the family was unable to face. (An actual decision or legal conflict was avoided only by heart failure.) The patient, unable to speak and too near resignation or too week to communicate by writing, of course had increasing inability to participate in any decisions. I wouldn't know what guidelines to define in such cases. I wouldn't even blame the hospital's conduct in any way as being motivated by income from keeping things going, although the initial surgery was perhaps motivated by the heart surgeon's personal interest; more likely it was his egotism about what he and his specialty could do.
The idea that at least expert panels, individual doctors, patients, and familiies should at least be the key player rather than the market or the values crowd may not pin down everything, but it's at least a first guideline, however. It was the core of the original Roe v Wade decision, and it's at the core of basic difference between the GOP hostility to science and human life on the one hand and us out here making real value choices in a reality-based community on the other.
John
http://www.haberarts.com/
June 20, 2007 9:03 AM | Reply | Permalink
Ah hah, same suspicion here! Mine actually denied it in a phone discussion with me when I raised it; that was, of course, after things started to look bleak for his decision, all of a sudden, it wasn't him who wanted to do it. Did you have the same experience of seeing how much power those heart surgeons have with making things happen? All the other docs seem to jump when they say jump. That's actually an example of what I meant about non-profit hospitals still having profit-like motives in this system. They like brandishing their star docs and fancy specialties, to get donors. The star docs also usually have private patients, their own website, with a nurse practioner to handle all their communications, etc., and have a vested interest in not having a high patient death rate. If I were them, I would not chose a patient with a poor prognosis to operate on, and would not admit that I pushed to operate on one where my operation did not work.
June 20, 2007 9:21 AM | Reply | Permalink
Thanks. I hadn't wish to put my story as exemplary of decisions driven by profit, not because misplaced incentives don't exist, but because I can't be sure of the motives and don't wish to make myself exemplary anyhow.
I'm aware of the temptation of anyone who likes to feel a professional to play god. At work as an editor, I can't believe that anyone won't want and take my advice on how to write. From my sideline playing arts writer, I know how seriously critics take their judgment, as if it's certain to make or break artists. An editor at Art in America wrote a column I once criticized blaming the inflated art market and inflated reputations on critics not judging enough. So I can only imagine what it's like for doctors, who truly are encouraged by their status, their role, the image of science, and their very job in relation to human life to be controlling. (On the up side, they're supposed to have relativity high job satisfication.) You're also likely to see a case through your specialty, like the old line about having only a hammer.
So I'll be cautious and say not that there were too many financial incentives, although this doctor has enough to do that he's in surgery for long days five days a week (with another day for rounds or office appointments with future patients). Perhaps it's just fairer to say that there are inadequate controls and disincentives.
John
http://www.haberarts.com/
June 20, 2007 10:05 AM | Reply | Permalink
I had a second thought that I should probably mention a few things I thought about the whole Long Term Acute Care thing, since I ended up doing a lot of research on it out of necessity.
Seems to me that this whole Long Term Acute Care thing is a very interesting result of our system. Looked to me like mainly two for-profit companies were created, mainly Select Specialty Inc., and part of Kindred, Inc., when they saw the unmet need to care for patients no longer wanted by I.C.U. but not ready for a nursing home and not necessarily a sure thing for hospice. The irony is: they were basing the whole business on Medicare being willing to pay for this, not like with nursing homes. And they got what they wanted from Congress: Medicare coverage. It's a pretty blatant racket in a way, Select Specialty especially, because all they do is lease a floor or two in a hospital and have their own staff and call it a separate type of care, so then it looks like the patient is moving on to another level of care, between I.C.U. and rehab. But it's basically just another I.C.U. as far as I could judge. And it's mainly to get Medicare to continue to cover inbetween hospital and long-term nursing home.
What I saw, results-wise, touring both companies facilities in one city is that Kindred, which is publicly traded, seemed to be more interested in getting patients and then once they have them, in keeping costs down, in order to show profit. Select Specialty, which is not traded on AmEx, but is expanding like wildfire, seemed more interested in getting patients and keeping families happy, for good word of mouth. Select Specialty is where my family member ended up because that is where the doctors and hospital referred. (Do they have an incentive to favor them? I don't know.) In any case, taking the tour beforehand was like getting a sales pitch from any salesman, they actually sent an R.N. to do it. The care? Interestingly, initially they seemed more open to attempting to do what the patient/famiy wanted than many of the "we are the gods, you listen" staff at I.C.U., very caring. The main doctor, I presume, was on salary, this may have had something to do with this attitude. The nursing staff was equivalent of I.C.U., which was, mho, 1/3 lousy attitude/burned out/overworked, 1/3 good, and 1/3 wonderful knowledgeable angels of mercy. Of course, you do not get all the bells and whistles of I.C.U. unless the doctors orders those things from the hospital his company rents space in. And you only get the specialists in the "groups" they work with (nearly every specialist in that city has joined up in non-competitive guilds, almost like unions, to deal with the insurance cos. & cut costs--need a kidney doc? they all have one of two same phone numbers and offices.) Overall, I was suspicious that, at the current time, this company is trying to get good word of mouth out in order to have the company grow, raise the value of the stock. While that's going on, they are going to try to keep family/patient happy. After that happened, the cost cutting would start, because, well, they are dependent mainly on getting fixed Medicare payment.
Correct me if I'm wrong on any of this, if you have the time, Maggie, I'm glad to learn more. I must say that the few financial articles I could find on Select Specialty were not that laudatory--some writers seem to mightly suspicious about what is going on therein.
June 20, 2007 10:17 AM | Reply | Permalink
rdf, taking the CBO .pdf you link to, and looking at the last column, accumulated debt, there is a very close correlation between administrations and relative movement in debt.
Given that there is some inertia in turning the ship of state, especially I would argue downwards -- it's easier ot spend than to cut -- there is a very obvious explosion from 1981 to 1992, debt stability 1993 to 2000, and a reexplosion 2001 to present.
Please discuss and explain.
June 20, 2007 11:16 AM | Reply | Permalink
I'm more interested in the figures for military spending. There are trends during different administrations, but the underlying cost of militarism doesn't change much.
The current rise in the deficit was caused by a) the wars, b) the tax cuts, c) the stock market crash, d) the downturn in the business cycle [ chose as many reasons as you wish ].
Cheney stated that deficits don't matter and in a certain sense he is (was?) right. As long as we can continue to borrow money from the Chinese we can continue to spend more than we have.
There are heated arguments among economists about whether the deficit is a "bad thing" and their positions don't even track whether they are left or right leaning. If you are interested in this sort of thing I suggest visiting the blog run by economist Mark Thoma. The topic comes up frequently.
The issue is that given a certain degree of deficit how are the available funds going to be apportioned. Since WWII the answer has usually been that militarism comes first.
--- Policies not Politics
Daily Landscape
June 20, 2007 2:11 PM | Reply | Permalink
Maggie makes good arguments for increased use of ethicists in our medical decision making.
In addition to the re-allocation of excessive defense spending and dismantling a wasteful and fraudulent US health care system we all need to practice personal prevention=behaviors and increase institutional prevention=public health.
That does not mean prevention solves all human health problems but it's more than you think! And the dollars thus saved can be allocated to the "Matthews" of the world.
Without sounding cruel or coldhearted I wonder how many congenital birth defects are preventable? As a doctor I should know- but I don't- and I doubt if there is scientific consensus on this matter?
Thanks Maggie Mahar
Dr. Rick Lippin
http://medicalcrises.blogspot.com
June 20, 2007 4:53 PM | Reply | Permalink
As some random observations, fetal alcohol syndrome is present, depending on the study, in 0.2 and 2.0 cases per 1,000 live births.
Neural tube defects, such as hydrocephalus and spina bifida, are often preventable with folic acid supplementation early in pregnancy. Since a woman may not know she is pregnant while at risk, a decision was made some years ago -- I don't know the history -- to require folic acid supplementation in baked goods, especially bread.
An irony here is that diabetic or prediabetic women might well avoid baked goods, so they won't get folic acid through that route. Since moderate folic acid supplementation (IIRC, 800 micrograms per day) lowers homocysteine, and there is an unclear correlation between elevated homocysteine and both general cardiovascular disease and stroke. My cardiologists have always wanted me to take supplemental folic acid, which appears harmless at 1 milligram per day.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
June 20, 2007 7:50 PM | Reply | Permalink
According to Wikipedia, "The cause of 40-60% of congenital physical anomalies (birth defects) in humans is unknown. These are referred to as sporadic birth defects, a term that implies an unknown cause, random occurrence, and a low recurrence risk for future children. For 20-25% of anomalies there seems to be a "multifactorial" cause, meaning a complex interaction of multiple minor genetic abnormalities with environmental risk factors. Another 10-13% of anomalies have a purely environmental cause (e.g. infections, illness, or drug abuse in the mother). Only 12-25% of anomalies have a purely genetic cause. Of these, the majority are chromosomal abnormalities."
From this, it looks like maybe 25% to 35% of birth defects are preventable, depending on whether genetic tests are available and used.
June 21, 2007 3:23 PM | Reply | Permalink
Thanks DragonFlyDC,and Howard also, for shedding some light on preventable birth defects.
Obviously from what you both say a significant % can be prevented
But I'm sure you would agree the fact that an individual person or a society that does not prevent STILL deserves compassion and treatment
Dr. Rick Lippin
June 21, 2007 7:00 PM | Reply | Permalink
Thanks DragonFlyDC,and Howard also, for shedding some light on preventable birth defects.
Obviously from what you both say a significant % can be prevented
But I'm sure you would agree the fact that an individual person or a society that does not prevent STILL deserves compassion and treatment
Dr. Rick Lippin
June 21, 2007 7:00 PM | Reply | Permalink
But I'm sure you would agree the fact that an individual person or a society that does not prevent STILL deserves compassion and treatment
Compassion is not the emotion used when one is part of the cause.
Debts and obligations seem more of what should be discussed.
We are inflicting this “SLAVERY” for what could be viewed as efficient production practices. I'm sure the Southern Planter of the past could explain better!
We can discuss America as a Society, but never as a Community.
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Today, are we searching for I deals or Ideals?
-Thinking
June 21, 2007 8:16 PM | Reply | Permalink