Questions Linger About Health Care Limits

Washington Post: Obama's Plans Go Only So Far in Addressing the Thorniest Issues Over Who Gets What Care

(Washington Post)  This story was written by Alec MacGillis.

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The question came from a Colorado neurologist. "Mr. President," he said at a recent forum, "what can you do to convince the American public that there actually are limits to what we can pay for with our American health-care system? And if there are going to be limits, who . . . is going to enforce the rules for a system like that?"

President Obama called it the "right question" -- then failed to answer it. This was not surprising: The query is emerging as the ultimate challenge in reining in health-care costs that now consume $2.5 trillion per year, or 16 percent of the economy. How will tough decisions be made about what to spend money on? In a country where "rationing" is a dirty word, who will say no?

The question permeates all levels of medicine: the use of tests that many argue are unnecessary (U.S. doctors order five times as many MRIs as doctors do in Germany); how early to intervene with common conditions such as heart disease and prostate cancer; how aggressively to treat patients nearing their life's end.

Although Obama and his advisers have held up providers' spending patterns as the crux of the crisis, proposals in Washington go only so far in addressing the thorniest questions about who gets what care. Instead, cost-saving measures are focused on introducing a public insurance option to compete with private insurers, or on general cuts in Medicare and Medicaid payments to hospitals.

The bills being written would put new emphasis on evaluating treatments according to their "comparative effectiveness," or weighing the risks and benefits of different types of treatment for the same illness, but the bills stop short of incorporating cost-benefit analyses into the findings or of requiring that providers abide by conclusions.

Lawmakers are also considering ways to reform Medicare payments to emphasize the overall quality of care over the quantity of treatments. But lawmakers are not going as far as Massachusetts did; it is considering shifting entirely from a fee-for-service model to one where salaried physicians would be paid an overall annual price for covering a given person or family.

Such a shift would probably be a shock to the system of many Americans, who have grown used to having any and all health-care options, regardless of cost, available to them.

"The questions of who gets what, these difficult choices . . . really are not posed in the current health reform legislation," said Drew E. Altman, president of the Kaiser Family Foundation. "The challenge," he said, "is us, the American people: We want the latest and the best, and we want it now."

The Democrats' caution has not kept Republicans from accusing them of embracing rationing. They raise the specter of the British agency, which goes by the acronym NICE, that decides whether that country's nationalized health-care system will pay for items such as costly cancer drugs that extend lives a few months on average.

"You're going to be saying to people, 'We're not going to care for you, because we've decided it's too expensive to care for you,' " said Robert E. Moffit of the right-leaning Heritage Foundation.

Others retort that the United States already has rationing: The uninsured and under-insured do not get the care they need. "We're already doing it," said Stanford University epidemiologist Randall Stafford. "We're just doing it in such way that it doesn't service societal interests."

But reformers are clearly spooked by the notion that they could be accused of denying, for example, hip surgery to an 80-year-old. In recent months, a federal panel has held hearings on how to spend $1.1 billion in economic stimulus money allocated for comparative effectiveness research. At each hearing, representatives of providers, industry and patient groups praised the research -- but then demanded that cost not factor into the eventual findings.

Scott Wallace, a Bush administration official who is now the Batten Fellow at University of Virginia's Darden School of Business, said factoring cost into treatment decisions would create the same backlash that HMOs encountered in the 1990s. "A mother of five with cancer wins against any rationing scheme ever created," he said.

Many physicians and health care-experts argue, though, that it is precisely by marshaling better research data, partly with the help of electronic health records, that a case can be built for limiting certain treatments. If doctors were to demonstrate to heart disease patients how few advantages coronary artery bypass graft surgery has over less expensive treatments, for example, many patients probably would not elect to undergo the surgery.

At Kaiser Permanente, the California-based health network that relies heavily on such research, Permanente Foundation Executive Director Jack Cochran said fears of treatment denials were exaggerated. Doctors, he said, need to be more realistic about not raising vain hopes about expensive, last-ditch treatments: "Comparative effectiveness is a hot-button issue because everyone sees their pieces of pie coming under scrutiny. But all of our pieces should be under scrutiny."

All signs in Washington suggest that cost considerations will be kept at arm's length as health-care legislation moves forward. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality, said the emphasis will be on clinical outcomes alone.

The draft legislation in the Senate Health and Education Committee, meanwhile, stresses that any research findings "shall not be construed as mandates for payments in coverage and treatment."

A senior administration official who requested anonymity to speak candidly acknowledged that while research might point to obviously wasteful practices, the reform would for the time being not get at the "harder question" of what to do "if new technology does work better and reduces risks but costs a lot more, and how to evaluate that."

The other half of the "saying no" challenge, reformers agree, is giving providers the right incentives and structures to deliver high-quality care as affordably as possible. The goal is to spread the "accountable care" models featured by the Mayo Clinic and others, where a network of providers works closely together to coordinate a patient's care, increasing the odds of keeping them healthy and decreasing unnecessary procedures.

Massachusetts, which has achieved near-universal health coverage but is struggling with high costs, is considering major changes in this direction. A legislative commission is about to release a report recommending that the state goad providers into joining networks that would receive payments for each enrollee, rather than for each procedure delivered.

Proponents say it would differ from the "capitation" approach -- fixed payments for each member -- used by the HMOs in the past because there would be more focus on performance and long-term value than on simply keeping costs down.

Skeptics say such a system would force the state's many solo practitioners or small groups of physicians into big networks and would renew complaints from the HMO era about limiting patients' choice. In Massachusetts, for instance, most parents with a sick child would demand access to Children's Hospital; and most cancer patients would want to go to the Dana-Farber Cancer Institute, no matter what network those were in.

The plans being considered in Washington do not go nearly as far in seeking to change providers' spending habits. They contemplate changing some Medicare payments from fee for service to a "bundling" system in which providers would be paid for an entire episode of care, giving them an incentive to reduce repeat hospital admissions. Another idea is to empower the Medicare advisory panel whose recommendations now tend to be ignored by Congress, or to create a separate, Federal Reserve-like entity to make tough decisions about federal health-care spending.

John C. Goodman, president of the conservative-leaning National Center for Policy Analysis, questions this approach, citing new research by his group that shows that areas with high Medicare spending do not correlate with high medical spending overall, suggesting that fixing excesses in Medicare will not necessarily translate to the broader system.

Henry J. Aaron of the Brookings Institution, who co-wrote a 2006 book called "Can We Say No?" said that real cost reform would mean giving all physicians incentives to leave behind the fee-for-service model for accountable care networks. The transition will take a long time, he said, and at first, people could still sign up for fee-for-service plans. But they would see their neighbors getting good care at a much lower price and hopefully switch over themselves.

"We're just not going to be able to all have everything . . . regardless of cost," Aaron said.

[sjc_1]

The National Health Insurance option would bring many uninsured into a plan. Much of any additional costs could be paid for by taxing health insurance paid for by employers as compensation, which it IS.

[CitizenMikeM]

Nothing of real value is free. The Public has to come to the realization that if they want the Government to provide such things as healthcare or long-term care insurance, etc. taxes have to go up. Value added tax, income tax, or taxes/surcharges on specific products can be acceptable to most if the Government will prove it will spend the income wisely (oversight by common citizens on boards or committees).

[lionbottt]

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[lionbottt]

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[erasmus111]

by incog-nito July 9, 2009 7:48 AM PDT
Say you don't like "socialized" medicine. Fine, but why would you put put with a system that puts people and their family at risk every time they change jobs or get laid off?

by erasmus111 July 9, 2009 9:27 AM PDT
Because they are freakin' brain dead.


Reply to this comment by CitizenMikeM July 10, 2009 4:25 PM PDT
They?!?


Meaning all the brain dead people that are against Universal, socialized, whatever, healthcare.

The problem is that they have been brainwashed. And in reality, don't even know what it's about. And also don't even take the time to find out.

[CitizenMikeM]

sorry, Erasmus--misunderstood your post.
My crystal ball doesn't see far enough into the future, but I see socialism in one form or another coming soon to a theater near us. It is almost inevitable. Capitalism appears to suffering from a near fatal self inflicted gun shot wound called GREED. Since it is a human frailty, we may not be able to recover from it, sepecially since the last twenty years or so, it has gone on unchecked by Congress inability to care or wean itself from the greedy teats it is suckling from.

[smoknmirrors]

"if religion were a thing to buy, the rich would live and the poor would die." If people really believe our government will design a system that is fair to all, accessible to all and affordable by all, they will earn lifetime membership in the Society of Those Who Think They'll Get Out Of This World Alive. Medical care IS a thing to buy, and the rich will live and the poor will die. Your doctor may decide what your best treatment is, but the government will decide who pays for it. The poor are compelled to accept that decision; the rich are not. That's the nexus of the dilemma.

[jsd330]

Everybody wants top quality health care at a discount price. Maybe Americas favorite discount store, Wal Mart will start offering cheap health care using Chinese doctors.

[erasmus111]

by incog-nito July 9, 2009 7:48 AM PDT
Say you don't like "socialized" medicine. Fine, but why would you put put with a system that puts people and their family at risk every time they change jobs or get laid off?


Because they are freakin' brain dead.

[CitizenMikeM]

They?!?

[incog-nito]

Every time the glaring flaws in the current system is pointed out, someone invariably says, "But it's still better than "socialized" medicine. Why change?". Never mind the overwhelming evidence to the contrary.

Say you don't like "socialized" medicine. Fine, but why would you put put with a system that puts people and their family at risk every time they change jobs or get laid off? Why put up with a system that, if you get too sick to work, you lose your work-based insurance just at a time you need it the most? Why put up with a system that is not easily portable but depends on your employment and your employer's prerogatives? A system that makes it harder for people to retire early, change career, go back to school for more education, etc.? A system that creates unnecessary burden and stress on people, even those who are insured?

No matter what people think about "socialized" medicine, one thing is certain: The current system is illogical and inefficient, and needs to go.

[inesje88]

Not only should all for profit health care be banned, our elected officials should loose their health insurance coverage until we the people (who pay for their and their families lifetime coverage), enjoy similar coverage. It is doubtful that the majority of our elected officials understand the health care crisis encountered by working Americans when his/her pokets are lined by not understanding it.

[abbe91]

Sometimes you need some benchmarks to see how a system is working. Let's have a look at infant mortality (number of deaths/1000 live births, starting with the best scores):

#224 Singapore 2.31
#223 Bermuda 2.46
#222 Sweden 2.75
#220 Hong Kong 2.92
#221 Japan 2.79
#220 Hong-Kong 2.92
(...)
#217 France 3.33
(You will find many of the West-European countries in that range, not going to copy them all)
#211 Czech Republic 3.79
(...)
#206 Slovenia 4.25
(...)
#193 United Kingdom 4.85
(...)
#190 Wallis and Futuna 5.02
#189 Canada 5.04
(...)
#181 Cuba 5.82 !!! despite the embargo
#180 United States 6.26
(...)

Source: https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

[didserve]

Somebody should tell these idiots that they dont have 10 years for a plan!

most of them wont be elected within the time this health care plan is completed!

America cant wait!

[nofoolling]

Until our leaders are willing to stop taking bribes from the Insurance companies and other health care corporations and start seriously talking about taking the profit out of health care, we are doomed and at the mercy of those who profit off the sick and needy in this country.

BAN ALL FOR-PROFIT HEALTH CARE AND HEALTH CARE RELATED PREDATORY CORPORATIONS NOW!

[incog-nito]

Let's look at our current system: Health care for your family (including spouse and kids) that depends on whether you're working or not, whether your employer offers it or not, and how much coverage your employer decides for you. If you're laid off or in between jobs, then no health care for the family (including kids). And if a member of your family gets very sick while without coverage, or if your insurer finds an excuse to deny coverage, then it's personal bankruptcy and financial ruin.

And yet there are people out there who don't think it's one of the stupidest systems ever devised by a nation. Amazing.

[npkppprc]

All this crap for according to Obama for 50 million americans without coverage which includes illegal aliens, I haven't heard where these figures came from. I'm sorry what is the population of the United States? seems like only a pimple if you look at the whole picture. I hope that your not into believing everything politcians say is the truth.

[skyk-2009]

I agree it is absolutely AMAZING! People SAY they do not want rationing yet it goes on EVERY SINGLE DAY. People say they want a choice in Doctors yet EVERY SINGLE DAY that choice is denied. People SAY they want coverage that provides their families protection and we DO NOT have it.

[ubrew12]

Single payer. Lets conclude what every other one of our capitalist trading partners concluded 30 years ago. How far behind does our ego really want to take us, after all?

[thusspokezara]

Here is how to reduce health care costs and increase basic coverage.
1. Limit what doctors, hospitals, and drug companies can charge.
2. Pay doctors only if the patient's condition improves.
3. Don't cover brand name medications unless they are proven superior to generics
4. Make doctors/hospital pay for extra cost associated with medical errors
5. Stop covering for the care of terminal conditions. Dying is NOT a medical disorder
6. Don't cover for the care of conditions caused by gluttony, addictions, poor judgment, and intoxication. (e.g. you get drunk and have to be taken to ER. YOU pay for it. You get pregnant and want an abortion, YOU pay for it. Pregnancy is NOT a medical disorder)