Wednesday, November 30, 2011

Rationing Health Care For Seniors

A sure-to-be controversial article appears in the Chicago Tribune this morning asking the sensitive question of 'Health care at any age, any cost?:'
"If you want to save all lives, you're in trouble," said Callahan, co-founder of The Hastings Center, a bioethics research institute in New York, and a faculty member at Harvard Medical School, in an interview. "And if you want to save all lives at any cost, you're really in trouble."

Callahan and co-author Nuland, a retired professor of surgery at Yale School of Medicine who wrote the best-selling "How We Die," were both 80 when the article was published.

"We need to stop thinking of medicine as an all-out war against death, because death always wins," said Callahan.
The article goes on the make some bold demands of doctors:
That said, McKoy believes doctors have a responsibility to spend medical resources where they do the greatest good. They must police themselves — otherwise, the government will come in and do it for them, she warns.

This is not easy, she said, describing the tremendous pressure doctors are under to perform procedures and prescribe medicine that will not help. And, she said, they often give in.

"We get selfish families, and it's often easier for doctors to pull out prescription pads," she said. "Doctors need more often to say no, to say (if a patient is dying): 'We will give you palliative care, but not give you chemotherapy. We will not give you new expensive drugs because it will not make you better.'"

Likewise, medical schools also need to train students to understand the cost-effectiveness of treatments, and to administer them based on medical research into their effectiveness — not just because they are available.
While I agree that the doctors on the ground should be making these decisions, I, too, have problems with a central regulator imposing a random age limit where all services to functional seniors stop. More importantly, this article ignores another reality for doctors who must make these difficult decisions: the nearly unlimited liability exposure if the family members disagree with all members of the health care team, including hospital ethics panels.

It's good we're having this discussion. And yes, since doctors are increasingly employed by hospital systems eager to fund their operations, pressure continues to mount on proceduralists to offer newer and advanced therapies to patients. But it's not all about the money. There really ARE wonderful therapies out there for seniors these days and, thanks to the virtually unlimited marketing of them to elders (especially via direct-to-consumer advertising) seniors will continue to demand them. Adding fuel to the procedural fire, lack of liability protections for health care facilities and doctors who opt not to treat a patient for some very good reasons will further add pressure on doctors and hospitals.

Once again, because of special interest resistance to malpractice reform, centralized government control will become the default option.

And maybe, just maybe, we need to rethink our stand on direct-to-consumer advertising of expensive medications to the populace on the Nightly News.



Tim Hulsey, MD said...

Our role as physicians will soon be limited to assuming the liability, which is the only part of our practices that has grown. As I have said before, the patient will pick a doctor's name from a list. She will never see him, but he gets all the liability issues related to her treatment. In fact, I'm sure the provider she does see will encourage her to take advantage of all legal recourse to get her "the money she deserves'" just as all welfare recipients are encouraged to sign up for all the benefit programs to get the most money they can.
When I die, as I float above my corpse, heading toward the light, I will be flipping a bird at the world that remains for #*+@$#* up my profession!

Craig Casey said...

Not only that, What about the patient's care? if the patient never sees the doctor what does that say about quality of care? In the end people still need to be seen by professional, their symptoms diagnosed in a remedy recommended. Courts of lawsuits Cannot do that. Healthcare rationing can kill you:

Tim Hulsey, MD said...

Craig said, "... people still need to be seen by professional."
Haven't you noticed how many health care "professionals" there are? We're called that so no one can discern whether they are being seen by a doctor, a nurse, a PA, or the janitor! And it's amazing how much less time it takes to be a "professional," since it is done in the name of cutting costs. I trained for 12 years and have been in Plastic Surgery parctice for almost 30 years. I can take your body apart, swap parts, rebuild parts, substitute synthetic parts. I can take out your entire parotid gland and leave you a fully functional facial nerve, just like I did on a lady this very day in only 2 hours. Soon, that will be taught in a 3 week course to produce Plastic Surgery Nurse Practitioners (PSNPs!!). What constitutes professionalim and expertise can be nebulous!
Craig also asked, "what does that say about quality of care?"
Quality care isn't the goal. Obama's 3 point shot is that old socialist shibboleth of universal coverage! Anyone can read from the treatment algorithm. Right?
COOKBOOK MEDICINE! Not good, but cheap!!

Lisa said...

Even though I hold exception to the idea that families are selfish (I think they are grieving) I think the idea that the idea that realizing by both Doctors and Patients that we will all die is an important step forward. It does not make sense to do an all possible efforts for someone who has a poor prognosis to a terminal disease. We really do need to consider the cost effectiveness of medical treatment. But I think that it puts an undue strain of physicians to have to bear the burden of policing the decisions. After all, most doctors really do not understand the costs involved in the care they request.