tag:blogger.com,1999:blog-8429570072441023296.post5922494947037270071..comments2023-09-07T06:36:59.520-04:00Comments on The Virtual Philosophy Club: END-OF-LIFE: Honest Brokers (not Death Panels :^)Ira Glicksteinhttp://www.blogger.com/profile/10800080810596424897noreply@blogger.comBlogger16125tag:blogger.com,1999:blog-8429570072441023296.post-4788924462833429292009-11-23T21:54:45.788-05:002009-11-23T21:54:45.788-05:00Thanks for your comments Howard. I'd appreciat...Thanks for your comments Howard. I'd appreciate it if you would weigh in on the new Topic recently posted by Stu.<br /><br />I watched 60 Minutes this past Sunday on <a href="http://www.cbsnews.com/video/watch/?id=5737138n&tag=contentMain;cbsCarousel" rel="nofollow">The Cost of Dying</a>. Thanks for providing a link so others can watch it on their PCs!<br /><br />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.<br /><br />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!"<br /><br />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. <br /><br />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.<br /><br />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. <br /><br />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.)<br /><br />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.<br /><br />Ira GlicksteinIra Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-46696644119571704782009-11-23T15:44:38.819-05:002009-11-23T15:44:38.819-05:00I found the reference for my last comment.
U.S. He...I found the reference for my last comment.<br /><a href="http://assets.opencrs.com/rpts/RL34175_20070917.pdf" rel="nofollow"><b>U.S. Health Care Spending</b></a> in comparison with Other OECD Countries. See pages 8, 11, 12.Howard Patteehttps://www.blogger.com/profile/12181204289094297715noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-91300177226522935332009-11-23T15:36:36.760-05:002009-11-23T15:36:36.760-05:00I agree that governments are always subject to the...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. <br /><br />For example,<a href="http://en.wikipedia.org/wiki/Healthcare_in_Taiwan" rel="nofollow"><b>Taiwan Health Care</b></a> per person is <$900. US health care per person is $6700. US administrative costs are <b>seven times higher</b> than the average of OECD countries. I believe it is also a fact that all OECD countries have government administered health care.Howard Patteehttps://www.blogger.com/profile/12181204289094297715noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-87229573777128084232009-11-23T15:21:49.315-05:002009-11-23T15:21:49.315-05:00Everyone should watch CBS Sixty Minutes on The Cos...Everyone should watch <i>CBS Sixty Minutes</i> on <a href="http://www.cbsnews.com/video/watch/?id=5737138n&tag=contentMain;cbsCarousel" rel="nofollow"><b>The Cost of Dying</b></a><br /><br />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 Patteehttps://www.blogger.com/profile/12181204289094297715noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-15935798992475530832009-11-18T21:57:38.548-05:002009-11-18T21:57:38.548-05:00According to ABC News this evening, Canada and mos...According to ABC News this evening, <b>Canada and most European countries with nationalized health care</b> recommend that routine breast cancer mammograms start at age 50, and every two years thereafter.<br /><br />The American Cancer Society recommends starting at age <b>40</b> (not <i>50</i>) and having <b>yearly</b> exams (not <i>every other year</i>) after age 50.<br /><br />The <a href="http://abcnews.go.com/Health/OnCallPlusBreastCancerNews/mammogram-guidelines-spur-debate-early-detection/story?id=9099145" rel="nofollow">United States Preventive Service Task Force</a> has American women and doctors up in arms over their recommendations this week that we adopt guidelines that match countries with nationalized health care. <br /><br />This government study concludes the cost and risks of early and yearly screening outweigh the small potential benefit in reduced deaths. <br /><br />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. <br /><br />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.<br /><br />It is time we have an honest discussion on these key issues.<br /><br />Ira GlicksteinIra Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-63716220107320682252009-09-16T23:00:35.569-04:002009-09-16T23:00:35.569-04:00Howard, as a conservative, the possibility of rati...Howard, as a conservative, the possibility of rational cost-containment appeals to me. (I am also an idealist at heart :^)<br /><br />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!<br /><br />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.<br /><br />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. <br /><br />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.<br /><br />Ira Glickstein<br /><br />"Hope springs eternal in the human breast"Ira Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-9946626341002445602009-09-16T22:46:06.897-04:002009-09-16T22:46:06.897-04:00While cost-effectiveness of some sort is entirely ...While cost-effectiveness of some sort is entirely rational, a recent <br /><a href="http://healthcarereform.nejm.org/?p=1785&query=TOC" rel="nofollow"><b>New England Journal of Medicine</b></a> poll shows that doctors strongly oppose any type of cost-effectiveness. <br />[Of course conservative doctors are more opposed than liberals.]<br /><br />That is going to make any implementation difficult. <br /><br />HowardHoward Patteehttps://www.blogger.com/profile/12181204289094297715noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-4375456580403654522009-09-16T22:30:03.063-04:002009-09-16T22:30:03.063-04:00Sorry, my keyboard seems to have gone mad. -JoelSorry, my keyboard seems to have gone mad. -Joeljoelhttps://www.blogger.com/profile/08770806025343971171noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-16287513430988535792009-09-16T19:14:52.885-04:002009-09-16T19:14:52.885-04:00I basically agree with John Sullivan. His approac...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. <br />http://www.nriol.net/short-term-health-insurance/<br /><br />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. -Joeljoelhttps://www.blogger.com/profile/08770806025343971171noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-84505207192983831672009-09-16T18:30:54.822-04:002009-09-16T18:30:54.822-04:00I agree John that a person who needs expensive hea...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.<br /><br />In the Health Savings Account (HSA) plan <a href="http://tvpclub.blogspot.com/2009/09/how-american-health-care-killed-my.html" rel="nofollow">David Goldhill suggested</a> 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. <br /><br />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.<br /><br />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.<br /><br />In the UK, an organization conveniently called "NICE" establishes standard <a href="http://guidance.nice.org.uk/" rel="nofollow">guidance</a> that informs cost-effective care in their public-funded system. <a href="http://www.bmj.com/cgi/content/extract/338/jan26_2/b181" rel="nofollow"><i>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).</i></a><br /><br />Ira GlicksteinIra Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-84199510086478966502009-09-16T13:39:46.403-04:002009-09-16T13:39:46.403-04:00To my thinking, the patient’s previous cost to the...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. <br /> 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.JohnShttps://www.blogger.com/profile/05221749229032990533noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-72359562205905821082009-09-16T08:46:46.302-04:002009-09-16T08:46:46.302-04:00John, interesting method of calculation, particula...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.<br /><br />Based on my reading of the <a href="http://en.wikipedia.org/wiki/Quality-adjusted_life_year" rel="nofollow">Qualiy-Adjusted Life Year (QALY)</a> concept, the patient's previous cost to the heath care system is not considered. <br /><br />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.<br /><br />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."<br /><br />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.<br /><br />Ira GlicksteinIra Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-53646665502813489332009-09-16T08:22:06.382-04:002009-09-16T08:22:06.382-04:00“As I understand it, the "honest broker"...“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.”<br /><br />Lets see how this might work. Must we resort to something like this in the future? <br /><br />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.<br /> <br />Guideline: <br />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. <br /> E = (A X P)/C<br /><br />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. <br />P = ((M /S)/R)X1000<br /> <br />An example: A patient 78 years of age is being considered for a procedure costing $60,000<br /> 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.<br />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. <br />P =((43000/36000) /2) X1000<br />P = 597<br />E = (78 X 597 )/ 60,000<br />E = .77<br /><br />Definition of the terms:<br />E = cost effectiveness of procedure <br />C =Cost in dollar for the procedure<br />A=age<br />P = physical condition<br />M = previous medical costs paid by health care system for the patient<br />R= current physical condition rated 1 to 10 by at least three doctors none of which practice together<br />S = standard cost of costs paid by health care system for patient’s ageJohnShttps://www.blogger.com/profile/05221749229032990533noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-25879105158020380942009-09-15T15:39:51.816-04:002009-09-15T15:39:51.816-04:00Thanks Howard for your unqualified agreement. Now,...Thanks Howard for your unqualified agreement. Now, how come the "gang of six" senators (three Democrats and three Republicans) cannot reach the same agreement?<br /><br />OK, John, you agree "at least in principle" but not in detail.<br /><br />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). <br /><br />They informed us it was not covered by Medicare so we paid the $40 out of pocket.<br /><br />Why does Medicare not cover tetanus shots? Because some panel of doctors and ethicists and government bureaucrats decided so.<br /><br />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?) <br /><br />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. <br /><br />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.<br /><br />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).<br /><br />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.<br /><br />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. <br /><br />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.<br /><br />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.<br /><br />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.Ira Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-81219329988248898842009-09-15T13:15:42.453-04:002009-09-15T13:15:42.453-04:00I’m going to repeat and agree with Howard’s commen...I’m going to repeat and agree with Howard’s comment, ‘Here, of course, I agree with you completely.” At least in principle.<br /><br />Still, the proof is in the details so I do have some reservations, not in the concept but rather in the details. <br /> <br />“…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”<br /><br />“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.”<br /><br />“government can … be an honest broker in assessing and evaluating treatment options. …”<br /><br />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.<br /><br />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.<br /><br />“… 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. …”. <br /><br />Potentially – what does that mean? From what was that extrapolated? Or did someone just make it up?<br /><br />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.JohnShttps://www.blogger.com/profile/05221749229032990533noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-6539068236512776152009-09-14T22:52:16.051-04:002009-09-14T22:52:16.051-04:00Ira,
Here, of course, I agree with you completely...Ira,<br /><br />Here, of course, I agree with you completely.<br /><br />HowardHoward Patteehttps://www.blogger.com/profile/12181204289094297715noreply@blogger.com