Thursday, August 20, 2009

Health Care

[from John] A previous Topic on healthcare discussed two issues I would like to discuss further. The first Outcome based Reimbursement needs further definition. The first definition, a modification of my proposal in the referenced blog is stated as definition 1.

Definition 1: Outcome based Reimbursement is a measure of whether the cost of treatment is sufficiently beneficial to the nation and the patient to justify payment by the healthcare system, if not the patient must seek his own treatment.

This definition has conflicting priorities - the nation and the patient. I’m sure in a patient’s view any treatment regardless of cost is justifiable as long as a reasonable quality of life is retained and should be paid by the health care system; on the other hand the nation, having many uses for its funds is most interested in optimizing the use of its funds therefore it must weigh the future value of the patient to the nation against the cost of treatment.

I agree that it is not in the best interest of a nation to treat its people cavalierly, still the further remote the decision making is from the patient and his doctor the more likely the decision will be made in favor of conserving funds. Therefore, a national government supervised (controlled) healthcare system is apt to make decisions based on precedence, standards and by rote. Thus, definition 2 seems to be a more probable definition of how Outcome based Reimbursement will be applied.

Definition 2: Outcome based Reimbursement is a measure of whether the cost of treatment is sufficiently beneficial to the nation to justify payment by the healthcare system, if not the patient must seek his own treatment.

If we accept definition 2 as the more probable result, each of us will be assigned a Quality-Adjusted Life Years (QALY) value based on certain criteria that will change over time as we age. How and at what level will this QALY value be defined and assigned? If done at a lower level, by the doctor or the hospital the result would not be much different from the present. However, if the doctor or hospital makes the decision will they be reimbursed by the health care system? Today, Medicare requires doctors to assign a code identifying the procedure performed. Medicare reimburses the doctor based upon this code. If they perform a procedure not covered, they are not reimbursed and must collect from either the patient or his insurance company. Insurance companies in turn normally reimburse the doctor or hospital only if Medicare authorizes the procedure. Thus, Medicare can be considered as a form of Outcome based Reimbursement.

The probability is very high that under OBR we will have a system very similar to Medicare with the exception that the QALY value will be combined with the Medicare code to determine whether the procedure will be reimbursed. Almost certainly, the QALY value will be determined at some national level as are the Medicare codes. Thus to be reimbursed my doctor will choose to perform the procedure not based on need but on a nationally published set of criteria or standards. The patient is only an artifact or a machine to be fixed or junked depending on his value to the nation.

The counter argument that if the system turns me down I can still seek treatment depending upon my net worth is spurious. If I my net worth just exceeds some arbitrary level then the healthcare system disavows me. All my assets may be needed as well as those of my family to obtain treatment or if I exceed that arbitrary level I will have to seek insurance while those just below that level obtain free treatment. Now the decision to perform a procedure and receive reimbursement from the health care system depends upon three factors, Medicare codes, my QALY and my net worth. Bah Humbug!

Lastly I was asked to address “the idea that end-of-life care costs an average of 50% (a number I read for the last year of life under the current system in the US), or could cost as much as 80% (according to President Obama). What do you think the actual number is?”

The objection I have is twofold the first is “the last year of life”. Let me address this first. I will admit that the examples are anecdotal in that they are based on my direct personal experience and not the part of a scientific study. However, they are diverse in their life experience and financial standings. Some poor, some middle class, some male some female. They lived in Minnesota, Texas, Arizona, Oregon, Illinois and Florida.

  • A lady dies at 100, I am not sure of the cause. She lived and died at home using a walker and meals on wheels. There was no hospitalization in the last year of her life.

  • A man in his nineties, caught phenomena, was hospitalized for about a week and died in the hospital. He was not hospitalized otherwise over the last year of his life.

  • A man in his seventies became ill, was treated on an outpatient basis until he had to be placed under hospice care for a week or so before he died.

  • A lady in her eighties died in her home of a heart attack. She had not been hospitalized over the previous year.

  • A man in his sixties, suffering from several heart related problems has been hospitalized on and off over several years. The combined costs of that hospitalization will certain exceed the cost of his last year of life.

  • A lady in her sixties had cancer and was treated, as an outpatient. The cancer went into remission for over a year. When it returned she chose no treatment and ended in an oncology ward for slightly more than a week.

  • A lady in her nineties was in a private nursing home when she broke her hip; she died after a short stay in a hospital.

  • A man in his seventies died of a heart attack while at home. He was undergoing no treatment at the time.

  • A man in his seventies, receiving outpatient treatment was in Hospice care when he died.

  • A man in his forties, a farmer, died while at work. He was not undergoing any treatment.

  • A lady in her forties died of a heart attack while at home. She was not undergoing any treatment.

With the exception of one man mentioned above, none of these people was receiving extensive treatment in the last year of their life. They are a diverse group of people. I cannot believe that they are exceptions but rather the norm. In their cases, where did the 80% of the cost of health care go?

It is a reasonable assumption that seniors require more health care than the average. We are at the end of our life. We are wearing out and require more care to extend our quality of life. I am not questioning that. Still let’s examine it from another direction. In the paper today, an article stated that the average life span for a male was 78 years and a woman 81 years. Thus, the life span as a senior is from 65 to 80 years of age– fifteen years. If you want to quibble 55 to 80 years of age – twenty-five years. On the other hand, the non-senior life span is 0 to 55 or 65 years of age. To state it differently, a person lives 55 to 65 years of his life as a non senior exposed to work hazards, accidents, birthing, childhood diseases, flu, other adult diseases, etc and then in his last 15 to 25 years to failing health. Considering 55 to 65 years of a lifetime is exposed to the natural hazards of life and 15 to 25 years as a senior, I believe a more reasonable figure for the cost of senior care over 15 to 25 years would be in the range of fifty percent.


Ira Glickstein said...

Thanks John for your thoughtful posting.

I have not been able to find the source of President Obama's estimate of 80%. Here is the link to the NY Times where he says "I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here."

I'm amazed the press has not asked Obama or his press secretary for the source of the 80% estimate. Parsing bama's words, it appears he is not talking aout just the last year of life and not just about the aged, but also the chronically ill, which can occur at any age. Cronic illness can result in some people being institutionalized for a decade or more, at great cost in public health dollars. Also, Obama used the word "potentially" which means he is not saying 80% is the case now, but, projecting trends in advanced technology that will keep the chronically ill and aged alive indefinitely that, unless we take some action on end-of-life policy, it could grow to 80% at some point in the future.

Your list of anecdotal evidence is good as far as it goes, but even those who spent only days in the hospital can run up bills of tens of thousands of dollars.

My bottom line is that, given limited resources, it is better to spend it on those who are likely to be restored to vigorous health.

For example, imagine two men of the same age. One is athletic and brok his hip skiing. The other is obese, a smoker and drinker with abad heart and liver who broke his hip slipping on the stairs.

A hip replacement in the US costs around $100,000. If we give it to the athletic guy (100% quality of life), who has a good heart and liver and is otherwise very healthy with good habits, he will be up on his feet in weeks and back to work (at nearly 100% quality of life) in months and will use that hip for decades to come. He is likely to "pay back" that $100,000 in services to his family and his employer and taxes. The obese/smoker/drinker was at 50% quality of life before he broke his hip. If we give him a new hip, it will cost more because it will take him longer to get back on his feet. He is likely to keep with his bad habits. His heart and liver will still be bad and when they go we will be on the hook for more expensive treatments. He will never get back to a satisfactory quality of life and will be a drag on his family and society in general. I think he is what Obama means by "chronically ill".

Ira Glickstein

Howard Pattee said...

The problem of staying alive (or keeping people alive) is not going to be solved by government regulations or by government funding. This is a culture-based “death denial” of mostly western technical societies that believe there is a rational or technical fix for every problem.

Lifespan will continue to increase because of technology that is largely funded by government agencies. Most biomedical gerontologists believe that biomedical molecular engineering will eventually extend maximum lifespan and even bring about rejuvenation (see Wiki).

The cost of these technologies continues to increase rapidly because of their complexity. The population age-distribution is shifting from productive youth towards the unproductive aged. Population growth by itself is ultimately the world’s greatest problem. Our present approach to medical care and technology is just making it worse.

I don't have a solution. Anybody?

JohnS said...

I agree with both of you, Ira and Howard. I was simply responding to the original blog. Ira, I cited several cases from my personal knowledge, if I were to say that one had extensive, costly care in his final year the lack of extensive care for the others mitigates the cost. However, let’s drop it.
I don’t have solutions but I have some thoughts. As Howard says, this is a culture-based “death denial” of mostly western technical societies that believe there is a rational or technical fix for every problem. I agree although I might extend the definition, it is also a Judeo-Christian ethic requiring us to make every effort to extend life regardless of the quality of life. Only God may make the final decision of when a person must die.
In Howard’s definition, time, discussion, education etc can possibly make western nations and others accept a more appropriate approach. In my definition, we are confronted by religious belief, which can be irrational and illogical although religious belief does change over time: as a populous becomes more educated, they tend to require religious leaders to rethink their positions. Abortion and heterosexual marriages are two examples.
The problem I see is that technology is changing so fast that our cultural and religious mores cannot keep up.
I abhor the thought that some national set of standards or guides will make life and death decisions although in a practical sense it appears necessary.
Another thought, could we give the patient a greater role in the decision-making? I emphasize the patient, not his doctor, not his family, not some ethics committee.
Suppose, each of us was permitted to prepare a statement of life retention conditions. (Observers would certify that the statement was made while sane and not under other duress.) That statement would have to be renewed or modified yearly. Let me use an example to illustrate the thought.

I, John Doe, do not want my life extended under the conditions listed below. I authorize my doctor to take the necessary steps to terminate my life. I instruct my family not to contest these desires.
a. An incurable illness that requires me to be permanently bed ridden and under heavy medication for pain.
b. At my age, 85, I become permanently blind.
c. I am mentally incompetent. That is I am unable to carry on a rational dialog, know and understand my surroundings.
d. Any medical procedures that will require extensive (expensive) procedures whose sole purpose is to extend my life.
e. If the quality of my life deteriorates below a reasonable level as compared with others of my age.

Signed: John Doe

This idea will give every do gooder, probably every liberal a heart attack because they want to make the decisions for me, but to me something in this fashion is preferable to having life and death decisions based upon some statistical set of criteria. It also has the benefit of reducing expensive life extending therapies.

Other thoughts:
Addressing tort litigation is necessary and can be done.
A means to share the cost of new drugs, therapies etc, although not reducing the cost of R&D, will reduce the cost of individual treatments.
More use of Urgent Care Centers to reduce the burden on Hospital emergency rooms.
Increase the authority of nurses and nurse practitioners to perform minor procedures normally restricted to doctors.
Encourage Doctors to share facilities to reduce the cost of overhead.

Ira Glickstein said...

I too agree with the general thrust of what John and Howard say. Along with what Joel said in a different thread, I am concerned that some people, due to their desire for expensive "heroic" treatment to keep themselves or a family member alive, raise the costs the rest of us have to pay from our common medical resources.

When my dad had a massive blood burst in his brain my brother and I took turns sleeping on a mat on the floor beside his hospital bed. When the doctor told me, based on a brain scan, our dad would not recover we quickly decided to have them remove everything, including IV and oxygen. The next night, a nurse came in and shoved a tube down his throat to suck fluid from his lungs and I told her to stop. My brother and I were with him when he passed away after a total of six days in the hospital. Had we not "pulled the plug" (which we knew he would have wanted) they could have kept him alive indefinitely at thousands of dollars a day in (mostly) public money.

Many (perhaps most) share our attitude and do not want patients who are most likely not going to recover to be given expensive life-extending care. Unfortunately, some people, out of a guilt complex or misplaced ethics, insist the doctors "do everything possible". The medical establishment, fearful of lawsuits and profiting by keeping hospital beds and operating rooms fully occupied, go along. This raises the cost of end of life care paid by everyone.

Advanced directives are a good approach, but what about those who do not or will not sign them? We need some general rule that limits futile care and protects doctors who withdraw artificial life support in qualifying cases.

How about this as a general rule: If a patient cannot breathe on his or her own and take nutrition by mouth, and if, in the view of two doctors, further medical care will most likely not restore him or her to that condition, any artificial life support, including oxygen and IV-nutrition, should be removed. During this period pain relief (such as morphene) may be given even if it may shorten the patient's life.

The "Judeo-Christian ethic" John refers to was established at a time when nutrition could only be given by mouth and there was no option for IV or oxygen or heart-lung machines, etc. Given the new technology, we have an ethical obligation to use it TEMPORARILY, WHILE DOING MEDICAL PROCEDURES, WHEN THERE IS A GOOD CHANCE THE PATIENT WILL RECOVER AND BE ABLE TO BREATHE AND EAT ON HIS OR HER OWN. Absent that possibility, artificial life support should be removed.

Ira Glickstein

JohnS said...

Itseems that we are in the same ball park although I would like to have the patient more involved. Not just tell his family his desires and hope they follow through. I would also like to see someone explore further two ideas - greater nurse and nurse practitioner's ability to treat patients so doctor can concentrate on more serious medical problems and greater use of urgent care facilities to relieve the load on hospitals. Both, I think would recuce cost, relieve doctor shortages as well as adding incentive for people to enter nursing careers. Think of it this way a nurse has the equivilant of a BS degree qualifying her to perform certain patient treatments, a nurse practitioner has the equivilant of a Masters degree and can perform a greater range of treatment while a medical doctorate degree is the equivilient to a PHD His training can best be put to use treating more serious matters.

joel said...

Ira wrote: For example, imagine two men of the same age. One is athletic and brok his hip skiing. The other is obese, a smoker and drinker with a bad heart and liver who broke his hip slipping on the stairs. etc. etc.

Joel suggests: I think this is a horrible way to govern health care. Suppose the athletic guy beats his wife and children. He lives off the importation of drugs though he's never gone to jail for it. The obese guy is a physicist who has contributed to the exploration of subatomic particles. He has written several fiction works though he has a tendency to drink a bit much. He is beloved by his family and colleagues who would miss him terribly if he dies. Letting quality be judged by anyone but the person whose life is in question or their designate seems Orwellian to me. -Joel

Ira Glickstein said...

Good try, Joel! If we had UNLIMITED public-funded health care resources, we'd give both of them replacement hips. With limited resources we need to make hard choices based on objective medical evidence that may result in one getting a hip and the other palliative care.

You seem to favor subjective criteria over objective ones? Kind of a popularity contest?

Would you allocate a liver transplant to the obese drinker because he is popular with family and friends? Or to the athletic non-drinker who may be a wife-beater and drug dealer but has never been convicted of any crime? (Of course, IF he had been convicted of a serious crime I would put him at the end of the health care line.)

If you let all decisions on spending public money for health care to be made by the person whose life is in question and will benefit, then most of it will go to the most selfish among us.

As for your suggestion that objective allocation of limited health care resources is "Orwellian" see Wikipedia"The adjective Orwellian describes the situation, idea, or societal condition that George Orwell identified as being destructive to the welfare of a free society. It connotes an attitude and a policy of control by propaganda, surveillance, misinformation, denial of truth, and manipulation of the past,..."

Ira Glickstein

joel said...

Note the tiny word "free" (society) in the definition of Orwellian. Using the excuse of limited public funding, you are taking away the freedom of the individual and putting great power into the hands of bureaucrats. As I said in a previous post, all we need to do is to leave the power in the hands of the individual before you extract their earned money and make turn it into "public funds." Health insurance can be between an individual and a regulated insurance mutual. Like Term Insurance it can be for a fixed period. Like Whole Life, it can be for a fixed amount. Like fire insurance, it can be denied to those whose house is already burning when they finally make application. Like home insurance, it can be designed with various deductibles depending on your choice.

Freedom is about having choices. Orwellian propaganda is about creating a crisis (like war with Oceana in 1984) so that security becomes more important than liberty in the mind of the individual. -Joel

JohnS said...

Joel is correct Ira. You said “Good try, Joel! If we had UNLIMITED public-funded health care resources, we'd give both of them replacement hips. With limited resources we need to make hard choices based on objective medical evidence that may result in one getting a hip and the other palliative care.”
Who is the WE? Yes, if we want socialized medicine then some WE will make the decisions and that concerns me greatly. Do we really need socialized medicine? Medicine controlled and administered by edict defined by Washington staffers or maybe under the supervision of a presidential appointed health czar.
Even though unfair in cases, a capitalistic system , with reasonable regulation, will prove better for the individual and the country. Let’s mend this system not place the entire health system under Washington’s blanket!

Ira Glickstein said...

Well, Joel and John are in agreement that we do not need or want socialized medicine - and so am I!

My health insurance was chosen for me by my employer, who pays part of the annual premium. My wife and I have only minor choices within their plan. We are both covered by Medicare. I assume you two are in a similar situation. Are you willing to give up your rights under your government and employer funded health plans? Of course not. You and I paid for that coverage. A private insurance plan with the same coverage would be prohibitively expensive.

Therefore, whether it is the government or a big insurance company rule maker, it is a "WE" situation. WE have a claim against a bucket of government money and a bucket of insurance pool money. Both are limited resources that need to be spent wisely.

"Outcome-based reimbursement" and "comparative effectiveness research" and "quality-adjusted life years" apply equally to public and private insurance pools. I think both public and private plans are spending too much money on we seniors. I look at the rapid advance of medical technology and the real possibility life may be extended indefinitely. That means costs for the chronically and terminally ill will grow as a percentage of total health care resources.

Ira Glickstein

joel said...

My employer had three health care insurance options; Kaiser Permanente, Blue Cross and Straub Plan. This is an example of the proper place of government legislation and regulation. Perhaps, if an employer provides health insurance there must be choice. If you start with a goal of maximizing individual freedom for all rather than societal efficiency, you come up with a different set of solutions than the ones we are being offered by those who profit from Big Government. -Joel

Ira Glickstein said...

I agree employers should offer choice in health care plans as yours did, Joel. Perhaps active and retired employees should be allowed to purchase any qualified health insurance, with the employee picking up any premium amount in excess of the employer contribution. I also like Sen. McCain's idea that health insurance companies be allowed to compete nationwide, across state boundaries, to give the consumer the widest possible choices.

Ira Glickstein