I made it back from Boston the other night after attending the Boston Atrial Fibrillation Symposium - a huge affair that has grown way beyond my expectations. There were very-well prepared talks with doctors from (literally) all over the world in attendance. (Imagine a football field with eight giant big-screen TV's at one end).
But traveling to and from was tough.
At lunch the last day, I sat with some nice nurse practitioners from Canada and asked them about how things work at their hospital in the electrophysiology department - after all they worked for a big regional hospital outside a major metropolitan city like mine. I asked how many electrophysiologists they had there: three - two of whom do afib procedures and one who does more device rather than ablation work. I asked how many defibrillators performed a year and asked who paid for them, and she said the government. "But we got authorization to do five more devices next year," she said.
"Only five?" I asked in disbelief.
"Yep, and we were lucky. Other centers got fewer. They're expensive, you know. We have to be very careful about who we select to get one of those. It's not like America - people here are used to waiting."
"But what about SCD-HeFT and MADIT-II and the other trials?"
She smiled and looked down at her plate. "We have no choice, people up here don't have to pay for their care, so we have to choose who we think the best candidates are and do the best we can."
Suddenly, I thought about American Airlines. That's because my cell phone rang. An automated lady's voice answered: "Hello, this is American Airlines. We are calling to notify you that your flight, number.... 1-1-7-8 from.... Boston to....Chicago O'Hare.... has been cancelled." The phone went silent. I held, hoping beyond hope that the voice would continue with more information, like if I was rescheduled on another flight and when that flight might be, or why, just my flight to Boston my flight was cancelled. None came: only a faint background hiss. Silence. So I hung up.
I called back to arrange an alternative flight. I waited.
I smiled as it dawned on me, just as before, that while many have championed that the health care industry should emulate the airline industry, the airline industry has also learned a thing or two from the health care industry in its time of cost overruns:
... like covert rationing.
And then I wondered: would America ever be capable of overt rationing, as in Canada?
-Wes
3 comments:
That's the million dollar question.
Never. If people demand to be seen ASAP in the ED for their stubbed toe while a code is going on (and throw a hissy fit when they don't), then people won't accept the fact that they can't be put on dialysis or receive that lifesaving AICD.
Though I am totally against the rationing in Canadian medicine, I wonder if the reason it does not lead to poorer health or mortality is because of the relative uselessness of our interventions. I have not read SCD-HeFT or MADIT-II, but even the abstracts leave us with a less than bright picture. An NNT of 18 (from MADIT-II) for one life saved might be considered good were we talking about a benign or cheap procedure, especially if it were only used for secondary prevention in a limited high risk group. But in the population that just wants one, or happens to have a cardiologist who thinks they help everyone with a poor EF, that is a bunch of expensive, unnecessary procedures paid for by someone else, no matter which country you live in, or which third party payment system you have.
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