Let’s Talk About Rationing

I published the last post at Open Salon also, where a jerk irresponsible person named neilpaul commented,

I think the NYT article on Sunday [the Peter Singer piece I wrote about here] about rationing has to be mentioned here. Jindal is relying on irrational fear of rationing among his followers to blind them to the bullshit aspects of his arguments. When people are terrified, they will believe any damned argument.

When I say fear of rationing is irrational, it is not because there won’t be any in the future. There will be. The fear is irrational because it will happen under any system and because rationing isn’t all that bad. It will actually make the system work better. As for the rationed, it will mostly be the elderly and they already had a good shot at life and have less to complain about than those who died young.

So this genius, have correctly understood that fears of rationing are irrational, goes and ahead and suggests that the right way to go about it is to withhold care from older folks. Yes, that will calm everyone down.

However, since I could not persuade him to STFU about killing off the old folks, let’s talk about rationing.

First, as Singer wrote, we in the U.S. have rationing now. Health care is rationed by ability to pay. As Singer said, we have more rationing here than in nations with government health care plans. There is utterly no reason to think that the plan Obama wants to put forward to make rationing worse, and lots of reasons to think there will be less rationing than there is already.

As I wrote recently in “Ir-rationing Health Care,” the Medical-Industrial Complex is pouring obscene amounts of money into medical treatments that doctors themselves do not believe will provide better outcomes than older, cheaper treatments. The for-profit health industry chases profits, not cures, which may be the biggest reason as a nation we get the worst outcomes for money spent on the planet.

I read in the Los Angeles Times this morning that our wonderful pharmaceutical industry has a new prescription drug out that grows longer, darker eyelashes. Also in the same article is the little tidbit of information that pharma spends more than $11 million a day advertising prescription drugs directly to potential patients, a practice that is absolutely unnecessary to the nation’s health.

The Obama Administration has declared it intends to leave choice of treatments in the hands of physicians, using Comparative Effectiveness Research not to ration, but to see to it that doctors get information on the effectiveness of treatments not from sales reps but from objective sources.

We also need to find ways to discourage doctors from over-prescribing and over-treating patients just to make money.

There are all manner of ways that the health care belt can be tightened. However, one thing is not being considered by anybody (well, except the insurance industry) is making choices about where to put our health care dollars based on the relative “value” of the patient. No industrialized democracy with national health care is denying care to older people as a form of “rationing.”

What nations might be doing is choosing not to treat conditions when treatment provides no real benefit, and prostate cancer is a prime example. As I wrote in the “ir-rationing” article, diagnosis of a slow-growing prostate cancer in an older man usually doesn’t warrant aggressive treatment, because the odds are the gentleman will die of other causes before the cancer becomes a problem. But this is not “rationing”; it’s logical medical practice. The treatments for prostate cancer have side effects that likely will cause more problems than the cancer and not lengthen the patient’s life by even ten minutes.

The important point is that the patient is not being denied care just because he is old. If the same elderly patient had another disease, even another form of cancer, in which treatment would improve the quality or length of his life, then he would get that treatment.

Peter Singer is an interesting guy, but he’s a philosopher. He’s not an economist or a policy wonk. As I wrote in the post about his article, I don’t disagree with Singer but I think his rhetoric was unnecessarily inflammatory. Yes, there are limits to health care as a commodity, but the cost-effective limits we are talking about now do not fit the definition of rationing, which is:

A fixed portion, especially an amount of food allotted to persons in military service or to civilians in times of scarcity; To restrict to limited allotments, as during wartime.

And that is not what we’re talking about. Nobody is saying any one group of people should have limits put on how much health care they receive. Rather, we’re talking about taking health care decisions away from profiteers and putting it into the hands of medical professionals who will make decisions based on what patients need. That is not “rationing.”

17 thoughts on “Let’s Talk About Rationing

  1. “slow-growing prostate cancer in an older man usually doesn’t warrant aggressive treatment”

    In general that statement is true however not all prostate cancer is so benign or slow growing, it depends on the “gleason” score (no relation to Jackie). As a relatively young survivor myself (my particular grade was lethal within 3- 5 years and I was dam lucky to get diagnosed, thanks to my brother) I can only offer this insight. Once you get diagnosed with cancer you really do want it out of your body as soon as possible by any means possible. I have met many men over 65 that had the surgery, and frankly more than a few seemed in at least as good of shape as me, some 65 year olds are actually quite youthful! Most good surgeons can gauge the usefulness of the procedure based on many factors age being only one.

    Sadly if we don’t get real reform it will be because the wing-nuts effectively scared the public into believing they won’t have a say in their health care decisions. And statements like:

    “If the same elderly patient had another disease, even another form of cancer, in which treatment would improve the quality or length of his life, then he would get that treatment”

    will be what the fear mongers hang their argument on. Proponents of reform should avoid specific scenario’s, cause its just sounds bad! We don’t need a big book of government health care procedures. We need the government to offer a collective and affordable insurance option administered by health care professionals.

    If we are really going to reform health care it’s gonna have to happen in stages, small steps. Doctors, nurses and patients need to be in charge. Not corporate bean counters, public bureaucrats, politicians, lobbyists or political pundits.

    Liberals should not lose sight that reform is needed to bring down costs and expand coverage, it will never succeed if it’s perceived as just an effort to purge profits and neutralize the powerful healthcare lobby (although that will be a nice side effect).

    • Uncledad — the point is that what we say we all want is a system in which doctors and patients can decide together what’s best for them. What we’ve got now is a system in which treatment choices are made based on whether someone can make money on them or not. Prostate cancer is a good example because obscene amounts of money are being spent on proton treatment centers that will provide extremely expensive treatment for prostate cancer, and which promise to make investors truckloads of money, yet there is no data showing that treatment will be any more effective than surgery, standard radiation treatments, or sometimes doing nothing.

  2. Maha,

    Proton treatments, WTF.

    I’m telling you when people with political motives start talking health care I start getting uncomfortable. This really is a subject that needs a whole new political consideration. Let’s avoid the big book of liberal health care guidelines.

    • Let’s avoid the big book of liberal health care guidelines.

      I agree. I’m not pushing “liberal” health care guidelines, but the guidelines recommended by physicians.

  3. Yeah this whole thing is a maze. And as usual we democrats are letting regular folks have their say. So we are not getting the carefully constructed and potent talking points that the wing-nuts usually have on display. It would be so much easier if we could all just get in line. But so be it we are liberals, hard to herd, meow!

  4. Huh? When did the only thing we need (sensible healthcare guidelines) acquire the adjective “liberal”? Someone’s been screwing with the dictionary again. Are there thinking people who really believe that poppycock?

    I read a blurb about physicians who own a diagnostic imaging company and guess what? The hospital where they work has one of the highest rates of prescriptions for scans and x-rays on record. Go figure.

    Even physicians see me and my shoulder problem as an opportunity for surgery and another boat payment…so I opted for PT and pursued it with a vengeance. It worked and flares up only when I skip the gym. Another physician told me that an emergent skin discoloration needed no attention but I insisted and biopsy revealed pre-canceerous melanoma that would have burrowed down eventually. So sometimes a low probability costly treatment is pushed and other times a cheap bit of insurance against something catastrophic is blocked. None of that makes sense in light of a cost-risk-rewards analysis.

    There are some cases when I do not want an insurance company ceo standing between me and my doc but there are also times when I don’t want a doc standing between me and the most effective treatment. The assurance that doctors must justify their choice of treatment based on known relative effectiveness will let me sleep at night. Government can elevate the facts to a level of pivotal importance. The idea that it is some know-nothing government bureaucrat making up “facts” is hseer nonsense and right-wing propaganda from monied corporate interests.

    Your GP is not didling with test tubes or running regression on reams of data before he pops into the exam room. Most physicians are practiotioners and get their info from others then apply it ON YOU! My most brilliant surgeon friend (magna cum laude, Washington University) tells me that most doctors are so inundated by drug and medical equipment making company sales pitches couched as research that they hardly know why they do are doing what they do. Who do you want pulling your doctors strings???

    It’s like the age old question of who will police the police. As with the police we need there to be proven standards (CER) and oversight. When someone disuptes the standards then they must prove it, not on Fox but among esteemed peers in the medical community. It seems that there is no sensible solution that will make conservatives happy since they apparently believe that anyone who could help stop the corruption is too corrupt themselves. In their world the sky is always falling except when they are in power.

    Even docs aren’t immune from the money bug but when we can be sure that doctors have no influences save what is best for patients then that’s about as good as it gets.

    It seems easy enough to know who is and who is not tainted by the conflict of interest but with only government at our disposal to counter monied interests when they ignore our health interests why do so many fear the only avenue available ?

  5. YES! CER is not rationing. You said it so well. But research requires a lot of highly paid people and new equipment and drugs will always cost more until commodotized. There is hardly anything that cannot eventually be commodotized. So maybe trial period for some new drug or procedure could be considered rationing. Aside from that I see little else of rationing. It’s a convenient argument but the burden of proof goes with it…to explain why the best treatments cannot go mainstream and be commoditized.

    Is it right for inferior to equal costly procedures be allowed to fund the refinedment and advancement of said procedure or should only success be rewarded? Even rightees say people want and deserve the best. I never got in line for an expensive procedure unless it was the absolute proven best course of action, though I could be pushed in the wrong direction by a doc. Fortunately I have a smart one now. Some aren’t so smart.

    A costly procedure without resounding proof of efficacy is just another scheme to line someones pockets. We are in bad need of standards but there’s that pesky problem of who will formulate and administer them. Last time I checked, health was ideology-agnostic.

    What we have to guard against is gouging and infinite exorbitant profit on things that our lives depend. Drugs and lifesaving procedures now so what’s next? Air and water? Manufacturers have proven time and time again that their profit sweet spot would leave many to die. So in that sense some are for rationing.

  6. Thank you for showing me that I’m not alone in thinking that advertisements for prescription medications is completely bizarre.

  7. When some complete Ass-hat advocates leaving the old folks out on the ice flow for polar-bears to eat when they get too ill, the best response is simply to tell them to STFU.

    If not that then ignoring them is the second best. Third best is to beat them into submission.

    Worst is to make a blog about their casual insensitivity.

    Nobody with a grain of sense would take it seriously. I.e. only Republicans would do so.

  8. I disagree with the premise that Singer is so off-base, though it is true he is inflammatory. He is making two points. First, pointing out that no “right” is limitless. This must be true for healthcare just as it is true for any other right. Second, he is attempting to develop an alternative model for decision-making instead of the profit motive. As it stands now, whatever heathcare reform is enacted in the US, nothing, and I do mean nothing, will change. Why? The proposals I have seen all revolve around keeping the profit motive intact in the US health care system. So long as that is the case, it is not accurate to say that decisions will be made on the basis of the best care. They will continue to be made on the basis of who will make the most money from a particular course of treatment. It is simply fooling yourself to think otherwise. Forcing poor people to pay so that insurers and doctors can profit will guarantee only that more poor people will become debt peons.

  9. I don’t think Singer is entirely off-base, either. My problem with Singer is not so much in his ideas as with the way he explains and contextualizes them.

  10. M–Fair point, though I would rebut with the point that it’s ultimately more important to start having some kind of discussion along the lines of what he’s talking about. Otherwise the fiction of “no rationing” will simply become a boulder in the road to any kind of real reform. I would also observe that when he started writing about animal rights he was considered pretty far out and look where we have come since then. The idea of health care as a right is a novel one, so it’s important to have the intellectual field remain as open as possible. Someone else can come along later and do the gilding (popularizing).

  11. Not familiar with Proton treatments but if they can shoot positive electrons into my ass instead of cutting it, I find that valuable if it’s equally effective.

    • I find that valuable if it’s equally effective.

      That’s the problem, if you go back and read the original Ir-rationing post. People are putting billions of dollars into building proton treatment centers, but there is no clinical or blind-study test evidence showing its effectiveness.

      The treatment involves a proton accelerator that can be as big as a football field, according to this NY Times article, and treatment at one of these places usually exceeds $100,000. If there was clear evidence that the centers really were effective at treating prostate or other cancer that one be one thing, but there isn’t.

  12. My mother died six months ago of Alzheimer’s. In the five years before she died, she had a Dx of lung cancer, radiation treatment for the lung cancer (although her docs were never able to confirm the cancer through biopsy), a long period of anorexia due to the radiation, a collapsed vertabra possibly caused by the radiation, vertebroplasty to stabliize the collapsed section of the spine, increased pain due to overfill of the vertabra, and the instillation of a morphine pump to alleviate the pain. About nine months before she died, a follow-up with her oncologist showed another “shadow” on a different section of the other lung. Her earlier cancer Dx had been made on the basis of CAT scans, MRIs, and PET scans, as I said, no biopsy ever showed cancer cells, nor were cancer cells ever found in any lymph nodes.

    When the new shadow showed up on a CAT scan, the doctor said she could order a PET scan, but asked my dad and me if we would want to put her through another round of radiation. Of course we immediately said we would not.

    In retrospect, I wish we had circled the wagons four years ago and considered not going forward with the first round of radiation. She might have still needed the pain management, as she had a long history of back injuries and severe pain, and the morphine pump really did work a miracle on the back pain.

    So I can speak to the rationing issue. My personal perspective is that we need to have frank and caring discussions about the options at the end of life. When my mother was finally admitted to hospice and I read the handout about all the signs of impending death, I knew my mother had been trying to die for at least six months, and we could have made food available to her without the arguments and bullying and drama (my parents were always big with the drama).

    I can talk about the hopeless frustration I felt from working with doctors who could not be arsed to communicate with other doctors, but it makes my head explode.

    It was an amazing experience being with her as she died.

    My point is that when the doctor introduced rationing, we agreed that it was pointless to conduct an expensive test when we had no intention of using it, and we might have entertained the notion earlier had it been offered to us.

  13. Proton treatments are the most effective radiation therapy for prostate cancer, but only a handful of facilities exist because the generator is huge and very expensive.

  14. Pablo,

    Proton treatments are the most effective radiation therapy for prostate cancer,

    How do you know that (other than from the companies that stand to make a profit from proton treatment)? The NY Times article cited says that no genuinely rigorous studies have been done, and there is no data available, to show that proton treatment provides a better outcome than more conventional treatment. Nobody knows what really works, it says. The only recent scientific study on prostate cancer treatments was done in Sweden in 2005, and that study concluded that surgery is probably the best option for men under the age of 65.

Comments are closed.