tag:blogger.com,1999:blog-8429570072441023296.post6900729324720880874..comments2023-09-07T06:36:59.520-04:00Comments on The Virtual Philosophy Club: Quality of Life and Quality Adjusted Life Years (QALY)Ira Glicksteinhttp://www.blogger.com/profile/10800080810596424897noreply@blogger.comBlogger9125tag:blogger.com,1999:blog-8429570072441023296.post-48557291328234218282015-05-22T19:18:38.864-04:002015-05-22T19:18:38.864-04:00Joel: Rather than say which intervention you would...Joel: Rather than say which intervention you would choose if you were responsible for your dear elderly grandparent (or parent) and if cost was no object because you were as rich as Bill Gates, you answered that, absent our free enterprise system, the high-tech intervention would not be available (presumably not even for Bill Gates's relative).<br /><br />OK, I understand and agree that if the US had a QALY (rationing) system for PUBLIC funding of health care, that would put a damper on the development of some high-tech interventions.<br /><br />However, so long as multiple PRIVATE insurance plans were available, the rich could choose plans with more generous QALY limits, of course at higher premiums. Or, the rich could simply pay cash to hospitals here in the US or abroad. I have absolutely no objections to more generous QALY limits so long as they are PRIVATELY funded and do not increase my health-care insurance premiums <br /><br />A potential benefit of a QALY system would be that it would encourage medical researchers and providers to develop more cost-effective treatments for the most prevalent conditions if that would drop the costs under QALY limits and make them available for PUBLIC and standard PRIVATE insurance funding.<br /><br />I have just experienced a prime example of what, to me, seems a waste of YOUR money to benefit ME and the Physical Therapist who recently treated me. As you know, I was diagnosed with Parkinson Disease a few years ago. I am on Dopamine, a relatively inexpensive drug that works fine for me. After the original diagnosis, my neurologist prescribed Physical Therapy (PT), and I took about a dozen hours of it over a couple months and thought it worthwhile. Well, after three additional years, my neurologist prescribed another round of PT, which I have just completed. It turns out that, with Medicare and our AARP insurance, there was no cost to me at all. I had no idea what the PT was costing until I asked and found out it was costing YOU (and your fellow taxpayers and insurance plan funders) over $2000 for each of my PT series! <br /><br />The PT therapists were, IMHO, quite competent and they really gave me the hours that were billed, and there was some benefit. HOWEVER, if I personally had to fund the PT I received, I would NOT HAVE DONE SO. <br /><br />That proves Milton Freedman's statement that when Mr. A (Medicare, insurance company and PT provider) uses Mr. B's money (taxpayer and major insurance premium payer) to benefit Mr. C (Ira, in this case), there is no limit to the amount of money that may be wasted.<br /><br />Please note that there was no lying or cheating or misrepresentation in the case of my PT. I really have the disease, the PT was of some (small) benefit, and the providers were competent and caring, using good equipment and techniques. Of course, as we know from many 60 Minutes and other investigative TV and newspaper reports, there is quite a lot of outright cheating in this area.<br /><br />Ira GlicksteinIra Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-28272363111867669192015-05-20T10:16:19.288-04:002015-05-20T10:16:19.288-04:00Hi Ira, The problem is that you probably wouldn&#...Hi Ira, The problem is that you probably wouldn't have the choice between a low tech intervention and a high tech system. The free enterprise system that we have now encourages resaerch and new development, but the rationed system does not. Thats why the rich and powerful come to the US for treatment. That's why people die while waiting for heart operations in Britain even if they qualify on a "merit" basis.Joel Foxnoreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-31758659142434719922015-04-18T22:06:15.265-04:002015-04-18T22:06:15.265-04:00Joel: I am, in general, sympathetic to your statem...Joel: I am, in general, sympathetic to your statement that:<br /><br /><i>"Health was an individual matter except when there were epidemics like the great influenza plague, polio and whooping cough. The intervention of government was necessary when public health required that vectors or carriers be isolated. In other words, it's not difficult to distinguish between public health and private health. They can be treated differently. ...<br /><br />"Suppose that all public health matters were completely funded by the government whether you are rich or poor. ... from the general tax fund ... All other disease would be treated privately by whatever private means might be available. The laws of supply and demand would function well and bureaucrats would not accrue more power. Private insurance would still be possible."</i><br /><br />OK. Say, under your favored scheme, outlined above, you were a middle-aged person responsible for the health decisions and costs for yourself, your loving spouse, child, and aged grandparent, who all had a normal health level and life expectancy for their respective ages. <br /><br />Then, one of them suffered a serious, life-threatening accident or illness and you had to choose between three general health care alternatives:<br /><br /><b>Intervention "A", the most complex and expensive,</b> requires extensive surgery or drug treatment that is potentially painful with an extended recovery period. If successful, "A" would restore the patient to 90-95% of normal health quality of life and life expectancy for his or her age.<br /><br /><b>Intervention "B" is moderately complex and costly</b> with a shorter recovery period. If successful, "B" would restore the patient to 70-80% of normal health quality of life and life expectancy for his or her age.<br /><br /><b>Intervention "C" is palliative care</b> to make the patient as comfortable and pain-free as possible. However, health quality of life and life expectancy would be considerably less.<br /><br />Obviously, all of the above is very general and predicted outcomes are necessarily uncertain. Yet, YOU, in consultation with the patient and doctor, MUST weigh the probabilities and make the decision, and (under your assumption of private funding) PAY for the treatment (or live with whatever restrictions might be imposed by the "Ford" or "Cadillac" private health insurance plan you purchased).<br /><br />So, how would YOU approach such a decision? It seems to me that in the above circumstance, I would consider the probable pain and suffering imposed by the treatment regime, the probable health quality of life and life expectancy that might result, and the relative cost-effectiveness of the choice. I would most likely choose something like "A" for my beloved child, "B" for myself and my loving spouse, and "C" for my dear aged grandparent. <br /><br /><b>In other words, I would use a variation of the Quality-Adjusted Life Years (QALY) scheme. How about you?</b><br /><br />But what if I (or you) was a rich as, say, Bill Gates? Would that change the choices? Perhaps I would upgrade to "A" for myself or my spouse, but I would most likely, out of compassion alone (since cost would be no object), still choose "C" for my dear grandparent. <br /><br />IraIra Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-44188488690083233882015-04-15T23:05:40.580-04:002015-04-15T23:05:40.580-04:00The above distinction between public and private h...The above distinction between public and private health, suggests a funding scheme. Suppose that all public health matters were completely funded by the government whether you are rich or poor. The money would come from the general tax fund just like the military budget. This protects the general population. All other disease would be treated privately by whatever private means might be available. The laws of supply and demand would function well and bureaucrats would not accrue more power. Private insurance would still be possible. Heart medication would be a private matter not to be government funded, but HIV drugs would be funded fully, but patients would be isolated as with other communicable diseases.Joel Foxnoreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-43193296948217971082015-04-14T18:58:33.780-04:002015-04-14T18:58:33.780-04:00You asked for alternatives. One would be to retur...You asked for alternatives. One would be to return to the days where we paid for services as individuals- no government-no insurance. The doctor was the wealthiest guy in the neighborhood and healthcare was affordable but expensive for most people. You only went to see the doctor if you really needed him. If you guessed wrong about your needs, you got very sick and/or died. You were your own "death panel." Then health insurance became popular as a fringe benefit in labor contracts. Going to the doctor was still expensive enough to cause people to grin and bear it. Competition between doctors kept prices low and research into new methods was at a minimum compared to the present. Health was an individual matter except when there were epidemics like the great influenza plague, polio and whooping cough. The intervention of government was necessary when public health required that vectors or carriers be isolated. In other words, it's not difficult to distinguish between public health and private health. They can be treated differently.Joel Foxnoreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-73997724253815126982015-04-14T09:16:06.378-04:002015-04-14T09:16:06.378-04:00Hi Ira, You repeat a statement "I understand...Hi Ira, You repeat a statement "I understand we spend more than half the dollars we will every spend on health care during the last year of our lives." The proponents of QALI have repeated this phrase unchallenged for a long time. It conveys an image of ancient people sucking up public funds unnecessarily. Cleverly worded, It neglects the fact that almost everyone is included in this statistic whether you die at 100 or twenty. My mother at age 42 consumed the majority of her life's medical expenses when she died on the operating table. Of course, it was the last year of her life! Her QALY score would have been very high. Using the words "LAST year" is automatically biased and the result appears shocking, because whatever kills you is usually serious and expensive to fight. I'll have some suggestions in my next comment. Joel Foxnoreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-18150273995116994852015-04-12T13:52:28.817-04:002015-04-12T13:52:28.817-04:00Jay: Thanks for your kind comments. I did not do a...Jay: Thanks for your kind comments. I did not do a new survey of the large crowd (over 80 people) at the April 3 meeting, but most seemed to generally agree with the results I presented from 2012.<br /><br />Joel: THANKS for your critical comments regarding QALY. I hope others join in with similar substantive comments leading to something like those dozens-long discussions between you, Howard Pattee, and me that still exist in cyberspace and still generate a surprising amount of traffic, averaging a bit over 100 page views a day.<br /><br />OK, I am not fond of "socialized medicine" and other basic undermining of our mostly-successful (compared to most other contemporary nations) mixed market-enterprise and government subsidized system).<br /><br />However, when it comes to medical care, paid for by private insurance pools (to which employers and individuals pay premiums) and subsidized by government social programs (paid for out of social security and taxpayer dollars), there HAS TO BE (IMHO) something like a QALY system to prevent abuse of the system by greedy doctors and hospitals rendering expensive service to sick, often old, and sometimes terminally ill patients.<br /><br />Milton Friedman said (something like), "When Mr. A (in this case the medical establishment) uses Mr B's (workers, taxpayers) money to benefit Mr. C (patient in medical establishment), there is NO LIMIT TO HOW MUCH MONEY WILL BE WASTED."<br /><br />What is YOUR alternative to insurance pools and Medicare using something like Quality-Adjusted Life Years to restrict the alternative care decisions of doctor and patient to choices that are cost-effective? <br /><br />If some rich person is using his or her own money to pay for medical care, I don't care what they choose to spend.<br /><br />But, when an ordinary person uses money out of an insurance pool or taxpayer funding THAT I HAVE PAID INTO (AND DEPEND UPON FOR MY FUTURE CARE, I want to be assured that we don't spend excess money on expensive Alternative A when Alternatives B and C are nearly as effective for a lot less expensive. <br /><br />I understand we spend more than half the dollars we will every spend on health care during the last year of our lives. That is not sustainable, and also cruel to the recipients of painful surgery who will most likely die within the year.<br /><br />So what is YOUR alternative to QALY?<br /><br />Ira<br /><br /> Ira Glicksteinhttps://www.blogger.com/profile/10800080810596424897noreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-17190950295620405952015-04-11T10:19:16.538-04:002015-04-11T10:19:16.538-04:00I dislike the notion of QALY because it's dish...I dislike the notion of QALY because it's dishonest. It creates a smoke-screen for what we used to call "socialized medicine." The failures of the European and British systems are well known. The use of QALY and other such computation devices lend an air of scientific respectability to yet another mechanism which undermines freedom of choice so well described by F.A. Hayek in "The Road to Serfdom." We, as a nation, need to have the discussion that starts with a definition of the difficulties with the free enterprise system of medicine and methods by which we could get more competition. Joel Foxnoreply@blogger.comtag:blogger.com,1999:blog-8429570072441023296.post-22075402852927076312015-04-06T09:02:24.757-04:002015-04-06T09:02:24.757-04:00Although my wife and I missed your April 3rd prese...Although my wife and I missed your April 3rd presentation, the information above was quite interesting. We would like to see the results from the 2015 meeting and how they compared to the previous meeting.<br /><br />We hope that you will be giving another talk on QALY at another venue. We always enjoy your presentations and try to clear our busy schedules to attend.<br /><br />Jay KaplanJay Kaplanhttps://www.blogger.com/profile/06450179619774183950noreply@blogger.com