Monday, September 14, 2009

END-OF-LIFE: Honest Brokers (not Death Panels :^)

President Obama, in a moment of unusual candor, expresses his views on end-of-life health care for those with chronic or terminal illness, published in the New York Times Magazine in April 2009 (full text from NY Times website, see section V).

“… government can … be an honest broker in assessing and evaluating treatment options. … when it comes to Medicare and Medicade, where the taxpayers are footing the bill …

“… using comparative-effectiveness studies as a way of reining in costs, …

“… 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. …

“…there is going to have to be a conversation that is guided by doctors, scientists, ethicists. … you have to have some independent group that can give you guidance.”

The government funded "honest brokers" envisioned by Obama will be doctors, scientists, ethicists, and bureaucrats who will use actuarial data to compare alternative treatment options, and, based on cost-effectiveness, provide national guidance as to which should be used when public money is funding the treatment, such as Medicare.

As a case-in-point, the President brought up the hip replacement received by his terminally-ill grandmother mere weeks before she passed away. During his campaign, she was diagnosed with terminal cancer and then, probably due to a mild stroke, she fell and broke her hip. Her condition was analyzed by her doctors who told her she had three to nine months to live due to the cancer. They also told her that a weak heart posed risks for the invasive surgery hip replacement.

In the absence of cost-effectiveness data or guidelines to the contrary, she chose the hip replacement, which was approved by Medicare and done mostly at public expense. She passed away two weeks later, sadly just days before Obama won. It appears the stress of the operation may have shortened her life by several months.

I don't know if Obama's grandmother got approval for the hip replacement because she was related to a prominent person. That would be bad enough, but it would be even worse if we are giving hip replacements and other stressful and expensive treatments to all terminally ill grandmothers and grandfathers.
"... in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. ... So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? 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."


Once upon a time, there was a boy in China and he saw his father carrying a large basket on his shoulders. "What do you have in the basket?" he asked.

"Well," said the father, "It is your grandfather."

"What are you doing with grandpa?" asked the boy.

"Well," he replied sadly, "Your grandfather is quite old and he is so sick that we cannot take care of him anymore, so I am going to dump him in the river."

The boy thought about it awhile, and then he said: "OK, Dad, ... But remember to bring back the basket!"

Of course the point of the story is that the boy will learn from his father's actions and will, when the time comes, uses that same basket to dispatch his father.

When my mom's cancer roared up after a year of chemo and radiation, she decided to accept only palliative care. Our family travelled to San Francisco where they lived and said goodby. Hospice provided morphene and a hospital bed for their apartment. We spoke by phone every evening for about a month until she passed away.

My dad made it clear that was what he wanted when the time came.

About five years later he had a stroke and fell and was taken to the hospital where an MRI confirmed a major bleeding in his brain that was terminal. He could not speak or hear or see and was being kept alive with IV hydration and nutrition and oxygen to help his breathing. My brother and I asked the doctors to remove all artificial life support, including the IV and oxygen, and he passed away a few days later.

I have asked my children to do the same for me when the time comes. "Remember to bring back the basket!"

Although I did not vote for him, and oppose much of his economic policy, I agree with President Obama's remarks on end-of-life treatment.
I wish he and his Democratic allies would be similarly honest in more recent remarks and I wish the Republicans who are characterizing the issue as "pulling the plug on granny" would be more thoughtful and helpful and honest as well.
I do not like to hear people call these "honest broker" government medical and ethical tribunals "death panels". However, the 'honest broker" guidelines, when imposed on Medicare and other public-funded medical decisions, will, in effect, cause many of the terminally and chronically ill to be given palliative treatments that will undoubtedly shorten their lives.

Whatever you call them, I believe we need ethical end-of-life guidelines to prevent doctors and hospitals from ordering expensive treatments that are not cost-effective (and that may be done more for reasons of fear of malpractice suits and/or simple greed to increase their incomes).

I am not if favor of further nationalization of US health care. However, with Medicare the primary payer for nearly all of us over 65, we need national guidelines to prevent the program from going bankrupt. (See this and this for more details on my views of what we really need in cost-effective health care reform.)

Ira Glickstein

PS: For the record, and in case the NY Times takes the page linked above out of their free access, here is the full text of the applicable section of the document from which I quoted Pressident Obama's words.
V. Post-Reform Health careYou have suggested that health care is now the No. 1 legislative priority. It seems to me this is only a small generalization — to say that the way the medical system works now is, people go to the doctor; the doctor tells them what treatments they need; they get those treatments, regardless of cost or, frankly, regardless of whether they’re effective. I wonder if you could talk to people about how going to the doctor will be different in the future; how they will experience medical care differently on the other side of health care reform.THE PRESIDENT: First of all, I do think consumers have gotten more active in their own treatments in a way that’s very useful. And I think that should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being — that, I think, can be helpful.
I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.
And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to
Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.
And right now we’re footing the bill for a lot of things that don’t make people healthier.
THE PRESIDENT: That don’t make people healthier. So when Peter Orszag and I talk about the importance of using comparative-effectiveness studies (see note below
) as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, you know what, we’ve looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions.
Won’t that be hard, because of the trust that people put in their doctors, just as you said? Won’t people say, Wait a second, my doctor is telling me to take the red pill, and the government is saving money by saying take the blue —THE PRESIDENT: Let me put it this way: I actually think that most doctors want to do right by their patients. And if they’ve got good information, I think they will act on that good information.
Now, there are distortions in the system, everything from the drug salesmen and junkets to how reimbursements occur. Some of those things government has control over; some of those things are just more embedded in our medical culture. But the doctors I know — both ones who treat me as well as friends of mine — I think take their job very seriously and are thinking in terms of what’s best for the patient. They operate within particular incentive structures, like anybody else, and particular habits, like anybody else.
And so if it turns out that doctors in Florida are spending 25 percent more on treating their patients as doctors in Minnesota, and the doctors in Minnesota are getting outcomes that are just as good — then us going down to Florida and pointing out that this is how folks in Minnesota are doing it and they seem to be getting pretty good outcomes, and are there particular reasons why you’re doing what you’re doing? — I think that conversation will ultimately yield some significant savings and some significant benefits.
Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —
Yes, where it’s $20,000 for an extra week of life.THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.
So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.
And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.
I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.
And it’s going to be hard for people who don’t have the option of paying for it.
THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?
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.
So how do you — how do we deal with it?THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

Note: Comparative-effective studies — which are now done by academic researchers, but not systematically across the medical system — review data to determine which widely used treatments do not improve outcomes and which effective treatments are not used often enough.


Howard Pattee said...


Here, of course, I agree with you completely.


JohnS said...

I’m going to repeat and agree with Howard’s comment, ‘Here, of course, I agree with you completely.” At least in principle.

Still, the proof is in the details so I do have some reservations, not in the concept but rather in the details.

“…there is going to have to be a conversation that is guided by doctors, scientists, ethicists. … you have to have some independent group that can give you guidance”

“The government funded "honest brokers" envisioned by Obama will be doctors, scientists, ethicists, and bureaucrats who will use actuarial data to compare alternative treatment options, and, based on cost-effectiveness, provide national guidance as to which should be used when public money is funding the treatment, such as Medicare.”

“government can … be an honest broker in assessing and evaluating treatment options. …”

So, an independent group will give me as a patient guidance. Doesn’t that say that somewhere in government a bunch of doctors, scientists, ethicists, economists, bureaucrats are going to establish set of guides, maybe a set of formulas that my doctor will have to consult and inform me that my the procedure I am considering will not be paid by whatever insurance is in place, private or public thus my choices are forget it or pay out of pocket? Also, guidelines are often a fixed set of definitions thus marginal situations are not tolerated. I’m am 67 years old and the average age of death is 78 thus I have 11 years to live and fit under the guidelines; however my friend, Pete, is 79 years old so he is not within the 10 year guideline so his procedure won’t be paid for.

By the way, isn’t this a form of mandated euthanasia? Sure, you may live a little longer with the procedure but we are not going to pay for it. We are willing to let you die.

“… 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. …”.

Potentially – what does that mean? From what was that extrapolated? Or did someone just make it up?

Where does the patient fit into these equations? What about quality of life? Will a person lie in bed staring at the ceiling, using a bedpan, until their time runs out? Not everyone, more probably just a few, will be able to pay for the procedure out of his or her pocket. If we are going to move in this direction, euthanasia should be an option. I still prefer David Goldhill solution.

Ira Glickstein said...

Thanks Howard for your unqualified agreement. Now, how come the "gang of six" senators (three Democrats and three Republicans) cannot reach the same agreement?

OK, John, you agree "at least in principle" but not in detail.

This morning I had a tetanus shot because I do work outside around the house and get cuts and my Chronic Lymphocytic Leukemia has compromised my immune system (at least according to my over-protective wife).

They informed us it was not covered by Medicare so we paid the $40 out of pocket.

Why does Medicare not cover tetanus shots? Because some panel of doctors and ethicists and government bureaucrats decided so.

I am sure someone on Medicare who does not have $40 to spare will get tetanus and perhaps die due to tetanus. So, that's the way it is. Any decision will, at the margins, be "life or death" but we have to make decisions and set limits (or else everyone will get a "free" tetanus shot and, then, how many may die from complications from the shot?)

As I understand it, the "honest broker" guidelines will consider both age and physical condition. Thus two people of the same age, but one with terminal cancer or a bad heart and liver, may get different decisions on, for example a hip replacement.

I don't know President Obama's grandma's age, but the fact she had terminal cancer, with three to nine months to live, plus a weak heart, should have ruled out the invasive and expensive public-funded hip replacement that may have shortened her life. It seems cost-effectiveness was not a consideration in her case. I think it should be, for public-funded treatments, in the future.

President Obama said, in the linked interview, that he would have paid for a hip replacement for his grandmother out of his (rich) pocket. I think those of us who have the money (as I did for my tetanus shot this morning) should be allowed to pay for non-covered items, including expensive operations, out of pocket (or by buying special high coverage insurance).

David Goldhill had the same solution, I believe. Under his system, if medicare does not cover a given treatment, and your personal Health Savings Account has been tapped out, you pay out-of-pocket or do without.

As for the bed-ridden patient on a bedpan, unfortunately many thousands are in this condition today and even the most expensive medical care could not prevent that for them.

I do not know where Obama came up with the potential 80% of all medical resources going for aging/chronic/terminal illness. He is not an expert in this area so some expert must have given him that estimate of what will happen if we do not set some guidelines with cost-effectiveness in mind.

We are, in effect, robbing our children and grandchildren of basic medical care when we deplete public respurces with expensive and non-cost-effective treatments for the aged/chronic/terminal.

My mother was on morphene to ease her pain when she passed, and that may have shortened her life. My father was not conscious when we cut off his IV and oxygen and ended his life days later. That was not euthenasia IMHO.

JohnS said...

“As I understand it, the "honest broker" guidelines will consider both age and physical condition. Thus two people of the same age, but one with terminal cancer or a bad heart and liver, may get different decisions on, for example a hip replacement.”

Lets see how this might work. Must we resort to something like this in the future?

I am going to be the “honest broker” and write a general guideline that is simple yet effective. An advantage is as the patient concerned I am in the picture plus my doctors have an important say.

A procedure will be considered effective and appropriate to be paid for by the health system if the cost effectiveness of the procedure (E) is less than 1.
E = (A X P)/C

To calculate E we must calculate the patient’s physical condition which is calculated by dividing the patient’s previous cost to the health care system (M) by the standard cost (S) to the system for patients of his age divided by rating (R) (from 1 to 4) agreed upon by at least three doctors who do not practice together.
P = ((M /S)/R)X1000

An example: A patient 78 years of age is being considered for a procedure costing $60,000
The health care system has paid out $43,000 in previous health care. The standard for a 78 year old person is $36,000. His doctors rate him as 2.
As calculated below his E rating is less than 1 so he would be qualified. If his doctors had rated him a 1 he wouldn’t.
P =((43000/36000) /2) X1000
P = 597
E = (78 X 597 )/ 60,000
E = .77

Definition of the terms:
E = cost effectiveness of procedure
C =Cost in dollar for the procedure
P = physical condition
M = previous medical costs paid by health care system for the patient
R= current physical condition rated 1 to 10 by at least three doctors none of which practice together
S = standard cost of costs paid by health care system for patient’s age

Ira Glickstein said...

John, interesting method of calculation, particularly your inclusion of the patient's previous cost to the health care system, which would be a measure of his or her general health.

Based on my reading of the Qualiy-Adjusted Life Year (QALY) concept, the patient's previous cost to the heath care system is not considered.

QALY is based on both morbidity (quality of life) and mortality (quantity of life). The idea measures the cost per QALY of alternative treatment options.

According to Wikipedia: "The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or have to use a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this."

If the cost per QALY is less than some preset value, say $30,000 per QALY, that treatment is approved for public funding. If not, it might be covered by special comprehensive insurance that might have a higher QALY limit. Or paid out of pocket if the patient, or his or her relatives and friends, can afford it. Otherwise, the doctor and patient will have to choose lower-cost alternatives, such as palliative care.

Ira Glickstein

JohnS said...

To my thinking, the patient’s previous cost to the system is an important measure for two reasons. First, the patient is deeply involved; it is a measure of how carefully he takes care of himself. A drug addict, or smoker or someone who abused his health in other ways would have run up a higher bill than one who exercised, ate well and took care of themselves. Essentially, they take themselves out of the system. This provides an incentive for us to take care of ourselves and teach our children the same. Secondly, an ideal healthcare system should treat everyone equally over his or her lifetime. Considering previous cost as part of the equation would tend to equalize the cost for everyone at the end of life. If the $60,000 cost in my example exceeds the guide line, maybe a lesser procedure at $40,000 would be acceptable and improve his quality of life although maybe not as much as the original procedure.
I don’t care much for the QALY concept. I have trouble applying the concept to a practical system although maybe someone can develop a thought experiment as I did to show how it would be integrated into a health care system.

Ira Glickstein said...

I agree John that a person who needs expensive health care due to self-inflicted diseases such as obesity from poor eating and exercise habits, liver or heart damage from excessive drinking and smoking, and so on, should be treated differently from those who live right. As you suggest, one measure of bad living would be prior medical expenses.

In the Health Savings Account (HSA) plan David Goldhill suggested and I agree with (#5 in my list), a person who has had large medical expenses in the past would have a tapped-out HSA, and would thus automatically have to pay more out-of-pocket for future care.

Also, QALY considers the resultant quality of your life if you get some expensive procedure. In general, an obese person with a bad heart will benefit less from a hip replacement, for example, than an otherwise healthy person.

One issue with your plan is that it would penalize a person who lived right but, through no fault of his or her own, had a genetic-based ailment or was struck down by a flu epidemic or got hit by an uninsured motorist and ran up high medical costs as a result. I don't think such a person should be penalized for high past medical costs when future medical care is at issue.

In the UK, an organization conveniently called "NICE" establishes standard guidance that informs cost-effective care in their public-funded system. Decisions made by the National Institute for Health and Clinical Excellence (NICE) about whether the NHS should fund treatments are based on cost effectiveness. NICE methods guides refer to a threshold of £20 000-£30 000 (22 000-34 000; $30 000-$45 000) per quality adjusted life year (QALY).

Ira Glickstein

joel said...

I basically agree with John Sullivan. His approach makes an effort to preserve maximum freedom of choice or minimum government interference i our lives. Isurance should not be a method to micromanage the citizen's life. Here's a sitethat provides quotes for short term insurance.

It has many options like any other kind of insurance. In a properly regulated market all customers in the same class should be treated equally. In other words, a person working for a large business should be treated no differently from an individual. There is no difference in the risk. The pool that the insurance company uses for actuarial purposes should be all the people in the state within which the insurance operates. If a person for whatever reason, chooses not to be insured, heor she should have that option an take the consequences. -Joel

joel said...

Sorry, my keyboard seems to have gone mad. -Joel

Howard Pattee said...

While cost-effectiveness of some sort is entirely rational, a recent
New England Journal of Medicine poll shows that doctors strongly oppose any type of cost-effectiveness.
[Of course conservative doctors are more opposed than liberals.]

That is going to make any implementation difficult.


Ira Glickstein said...

Howard, as a conservative, the possibility of rational cost-containment appeals to me. (I am also an idealist at heart :^)

However, I can understand how a conservative doctor, who has had experience fighting with stubborn, inflexible Medicare (and private insurance) bureaucracies, could come to the conclusion that the government will never get anything right!

There is also the experience in Europe where doctors, on average, under different flavors of government-dominated universal health care, take home half the pay they do in the US. So there could be some understandable selfishness involved as well.

I think the liberal doctors who answered the linked NEJM survey and said they favored cost-effectiveness regulations were just giving answers that made them feel good.

Nevertheless, I still favor rational cost-effectiveness and i think we shoul dlook tothe NICE example of how they do it in the UK and adapt and improve it for our benefit.

Ira Glickstein

"Hope springs eternal in the human breast"

Ira Glickstein said...

According to ABC News this evening, Canada and most European countries with nationalized health care recommend that routine breast cancer mammograms start at age 50, and every two years thereafter.

The American Cancer Society recommends starting at age 40 (not 50) and having yearly exams (not every other year) after age 50.

The United States Preventive Service Task Force has American women and doctors up in arms over their recommendations this week that we adopt guidelines that match countries with nationalized health care.

This government study concludes the cost and risks of early and yearly screening outweigh the small potential benefit in reduced deaths.

This is a clear example of the Comparative Effectiveness Research (CER) and Quality Adjusted Life Years (QALY) methodology common in the UK and other countries with nationalized health care.

So far, proponents of the House Health Care bill, and most of the media, have avoided talking about CER and QALY. As I said in my original "End-of-life: Honest Brokers (not Death Panels :^)" Topic, I do not favor nationalized health care in the US, but I do support CER/QALY methodology.

It is time we have an honest discussion on these key issues.

Ira Glickstein

Howard Pattee said...

Everyone should watch CBS Sixty Minutes on The Cost of Dying

The basic problem is religious conservatives’ inability to accept death of the aged as often involving a human choice (i.e., triage or "death panels"). This makes it a political third rail, as we have seen in the current media.

Howard Pattee said...

I agree that governments are always subject to the same corruptions as private enterprises, no better nor worse. The fact is that the complex US health system is by far the most expensive in the world while its quality, especially for the young, is below average.

For example,Taiwan Health Care per person is <$900. US health care per person is $6700. US administrative costs are seven times higher than the average of OECD countries. I believe it is also a fact that all OECD countries have government administered health care.

Howard Pattee said...

I found the reference for my last comment.
U.S. Health Care Spending in comparison with Other OECD Countries. See pages 8, 11, 12.

Ira Glickstein said...

Thanks for your comments Howard. I'd appreciate it if you would weigh in on the new Topic recently posted by Stu.

I watched 60 Minutes this past Sunday on The Cost of Dying. Thanks for providing a link so others can watch it on their PCs!

I was particularly angry with the old, dying man who had the nerve to expect a $400,000 heart and lung transplant (I am going from memory but I think that is what it was). It was courteously and gently explained to him that he had a choice of asking the staff not to resussitate him if he had a heart failure and the SOB insisted he wanted to be revived and kept alive as long as medically possible.

My wife happened to enter the room as I was watching a later part of the segment and she heard Steve Kroft announce that the man had died some weeks after the interview. Not knowing the story, she said "that is sad". I exploded and shouted, "I'm glad he died. He expected a $400,000 heart and lung operation at my expense and, at $10,000 a day to keep him alive, he wasted my money!"

The 60 Minutes story was excellent. The main doctor interviewed was very reasonable on how terminal patients and their families should be advised of their options for a peaceful end of life.

My only problem with the segment, and TV and press coverage in general, is that they do not make any attempt to explain Comparative Effectiveness Research (CER) and Quality Adjusted LIfe Years (QALY) to the general public.

I don't agree with you that it is only the "religious conservatives" who demand the everything medically possible be done for themselves (or their loved ones), without regard for cost. I think plenty of non-religious people and liberals feel that way as well.

Indeed, religious people, in general, should welcome death when the time comes, and accept God's will rather than demand heroic medical intervention. Conservatives should be concerned with fiscal responsibility and their duty to the next generation. When it came to her parents, my wife was the one who asked the doctors to set a "do not resussitate" order when the time came. My brother and I did the same when my father was at his end of life, even withdrawing oxygen and IV. (He happened to be in a Catholic hospital and they readily agreed with our decision.)

I think it was the leftist feminists, not the religious right, who derailed the new mammogram guidelines. They equated it to putting money ahead of a potentially small increase in deaths from breast cancer.

Ira Glickstein