Thursday, June 21, 2012

Rationing, Waste, and Useless Interventions

Most people, when they or those they love are sick, want things done for them that might be of benefit. Cost is a secondary factor, especially when it is not directly being borne by them because they have health insurance coverage (but if it is going to be costly, that insurance better be good). In general, the order of preference would be for: 1) things that will definitely help; 2) things that might help; 3) things that almost certainly won’t help-but-you-never-know and don’t cause serious harm; and 4) things that won’t help and may very well cause serious harm.

It might seem superficially as if most people wouldn’t want #4 interventions, but surprisingly people opt for them. This is particularly true when the expected outcome is death; if you’re going to die anyway, what harm could be greater? Besides, maybe a miracle will occur. Of course, there can be greater harm than simply dying – death preceded by increased suffering caused by futile attempts at treatment – but when confronting death, many people look at the positives and ignore the negatives. In addition, the decision may be different when made by the person actually facing death (provided s/he is conscious and competent – or has advance directives -- and isn’t doing what the family, not s/he wants, because s/he is used to caring for them) or by his/her loved ones.

This leads into a discussion about rationing of health care resources, which is, appropriately, achieving a lot of attention. Two “Perspective” pieces in the New England Journal of Medicine May 24, 2012, and a “Viewpoint” from JAMA, May 23/30, 2012, address these issues from slightly different, well, perspectives/viewpoints. Howard Brody, MD PhD, in “From an ethics of rationing to an ethics of waste avoidance[1], as a bioethicist, begins with providing the ethics of rationing: “First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.” I’d say “certainly unfair”; while Brody is talking in the abstract, we need only look around at what is actually occurring in the world to know that we have rationing that is unfair. He adds “The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too.”

Brody addresses the current importance of this discussion given recent studies that show that as much of 30% of health care expenditures are “waste”, as opposed to less than 10% that might be attributed to “deliberate fraud.” Eliminating fraud is important, but it is a “one-time” saving, whereas eliminating waste not only represents a bigger number, but, because doing more and more tests is a major driver of rising health costs, may represent a way to “bend the cost curve.” Of course, as I noted, what is “waste” can depend upon ones perspective, values, and even degree of selfishness. Certainly because, as Brody notes, one person’s health expense (even if it is “waste”) is another person’s income, this is not going to be an easy discussion.

Brody cites the case of treatment of advanced metastatic breast cancer with high-dose chemotherapy followed by autologous bone marrow transplantation, which was “…initially thought to offer perhaps a 10% chance of a significant extension of life for patients who would otherwise be fated to die very soon. Insurers’ refusal to pay the high costs of this last-chance treatment did much to torpedo public trust in managed care during the 1990s. Data now suggest that the actual chance of meaningful benefit from this treatment is zero and that the only effect of the treatment was to make patients’ remaining months of life miserable.” However, it could have gone the other way; maybe longer experience would have shown it to be more effective. The “torpedoing of public trust” was surely enhanced by protests from advocacy groups as well as from physicians and hospitals that benefited financially from these procedures. Another result, noted by Volpp et al., in JAMA Assessing value in health care programs”[2], is that “Many insurers, including Medicare, are continuing to cover bevacizumab for metastatic breast cancer, despite the unanimous recommendation by a US Food and Drug Administration panel that it not be covered because it is not helping patients to live longer, does not control their tumors, and exposes them to serious adverse effects, and despite an average annual cost of $99,000.”

Volpp and his colleagues  argue that, in health care, return-on-investment (ROI) cannot always be measured directly as positive in dollar terms, and is less so as the pool (everyone, a big company, a small company, an individual) is reduced:
What would happen if the rule were applied to every health care decision that is made? Besides childhood vaccination and flu shots for the elderly, few health care services save money. The positive return-on-investment criterion is not applied to most health care services because almost nothing satisfies it. Medicare is prohibited by law from considering cost in coverage decisions, and other insurers tend to follow suit, even if the benefits are small and the costs very large. Would anyone ever ask, ‘What is the return on investment in treatment of this patient’s cancer?’ This is not a meaningless question, but almost certainly one that most people would think inappropriate to ask.”
They add “It certainly does not make sense to use one criterion—Are there clinical benefits?—for coverage decisions for treatments and a different criterion—Are health care savings greater than program costs?—for preventive services or for delivery system innovations designed to improve health;” however, we certainly do.

The third article, “Beyond the ‘R Word’? Medicine’s New Frugality”[3] by M. Gregg Bloche MD JD, takes a more policy, political, and law-oriented approach toward understanding what might happen in limiting health care expenditures. He discusses the medical “luxury tax” (on “Cadillac plans”) and notes that while this is not having a big impact now, with the threshold at $23,000 a year, it will in the future because costs of medical care (and insurance) rise faster (at least 2% and often more) than the consumer price index (CPI), while the threshold for the tax is 1% above CPI. He suggests that “Employers
will pay the tax, but workers will bear its burden as firms shrink salaries to cover the cost.”

This is really important, and it is another strong argument for a single-payer health insurance program that will cover everyone. Costs do – and will continue to need to be – controlled, and this will result in continued rationing. But that rationing is only ethical when it is explicit and based on medical need, not the character of one’s insurance or socioeconomic status.

[1 Brody H,”From an ethics of rationing to an ethics of waste avoidance”, NEJM 24May2012;366(21):1949-51
[2] Volpp  KG, G Loewenstein, DA Asch, “Assessing value in health care programs”, JAMA 2012May23/30; 307(20):2153-4.
[3] Bloche MG, “Beyond the ‘R word’: medicine’s new frugality”, NEJM 24May2012;366(21):1951-3.

1 comment:

Bob Bowman said...

Waste can also be more types of costs to deliver primary care and higher costs in each cost type. These are generally costs that do not improve care and some result in less primary care delivery:

Recruitment and retention
Administrative costs to maintain recruitment and retention including private brokers and government brokers
Electronic records and other diversions of health spending outside of health care delivery
Board certifications and maintenance
Numerous certification efforts for professionals and clinics
Student training experiences of a few weeks in length
Various diversions of resources from health to legal or other components of society

Fragmentations that are increasing and worsening by design in the US, increase the burden upon primary care offices and nurses and can decrease volume and revenue, in addition to burnout and turnover impacts:

Hospitalist fragmentation
Emergent and urgent fragmentation
Hospice, home visit, corporate, retail, convenience care

Concierge, collaborative, nurse managed, pay for performance, and other moves to less volume represent waste as they all move to less primary care per graduate with all of the consequences of ever more millions with declines in health access.

Being a nice fit for individuals, groups, institutions, associations, and special interest groups is the major problem facing those who actually deliver health care.

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