Health Care Rationing in Federal Bill

Discussions for Patients, Family, and Friends HD For Patients
41

Unregistered,

Bill’s post about the US health “system” (I don’t even like to refer to the healthcare chaotic mess as a system) is absolutely brilliant and spot-on.

There is a cost difference between nocturnal HD, which has been successfully done in Tassin, France, every other night, for 30 years–with double the survival we see here in the US for standard in-center HD, and daily dialysis, which requires 5-6 treatments per week. Nocturnal HD can be done within the current, flawed reimbursement system. Daily requires additional funds–though with all costs it is likely still more cost effective (and with better outcomes) than standard. If you don’t compare apples to apples, you won’t get the right result.

From what I’ve seen, a “free market” for healthcare has meant using health insurance companies whose main aim is to not spend money. If you’re looking for healthcare innovation, that isn’t the way to get it. A single payer system that will cover everyone and eliminate the incentive for cherrypicking the healthy so as to leave the ill out in the cold has to be an improvement. IMHO, it would be challenging to make our current “system” any worse.

Getting access to poorly delivered, uncoordinated care faster isn’t much of an advantage.

A single payer system with opt-out options for those who have better resources would be a good fit for the US, and would eliminate those “waiting line” issues you seem to be so troubled by. But the reality is, there are likely to be some difficult decisions about rationing in the future, and I didn’t see anyone respond with answers to the questions I posed earlier.

42

you say:

– Is it appropriate to give everyone with kidney failure dialysis indefinitely? Comatose people with multiple illnesses who are being transferred to and from a nursing home three times a week?

Now really, what % of patients are we talking about…but to answer your question, yeah there’s a case to be made that comatose people in the last stages of life where the Doctor decides that we have to pull the plug.

People with other terminal illnesses, like Alzheimers? (I got a call about this!)

Wow, now your getting interesting. My mother in law had Alzheimers for 6 years before she died. So exactly when would you like for me to pull the plug on her?

. How about people who don’t even want dialysis, but whose families want them to have it?

So your answer is just to have Daschle (or someone like him) decide? Interesting.

– How do we assure that taxpayers are getting value for our dollars, and not just enriching a doctor or a clinic who is looking upon each patient as a “revenue stream” and not paying any attention to their quality of life?

There’s no way to regulate greed and uncaring people, sorry. But you might apply the same standards to politicians and government employees.

Can we give everyone every treatment?

That is never going to be in the cards. You have suggested “single-payer” with and op-out for the Rich. So I think your own model fails this test.

Sadly, I now see that this thread is getting bogged down with too many Unregistereds. I am not the unregistered who did the original Bloomberg post, I just happened to stop by your site.

However, I see a lot of wishful thinking. That if we re-designed Medicare, things would be better. I can’t share your optimism. I saw Daschle giving a speech on CSPAN some time ago. His general principles were: Cost Control and whatvever legislation is drafted must be moved thru quickly and it must be Vague.

I’m sorry, that doesn’t give me a lot of confidence. I like sunshine and specificity in my legislation.

You derogate free-markets as if we were still in Upton SInclair’s time. But free-markets have given us the ability to have MRIs CAT scans and a myriad of medical products that are everywhere, and surely you know that. And yes, we have a mixed-economy now…in fact 50/50 for healthcare.

Meanwhile, we’re still waiting on the Comparative Effectiveness study first proposed in 2001.

Bill wants early CKD screening…ok, let CVS set up small clinics in their stores and do cheap UA and bloodwork.

Let’s be creative. Single-payer is not creative. Truman was the first to propose it. Sixty years ago, almost as long ago as Upton Sinclair.

43

A (former?) icon of Liberals, George McGovern had this to say recently:

Health-care paternalism creates another problem that’s rarely mentioned: Many people can’t afford the gold-plated health plans that are the only options available in their states.

Buying health insurance on the Internet and across state lines, where less expensive plans may be available, is prohibited by many state insurance commissions. Despite being able to buy car or home insurance with a mouse click, some state governments require their approved plans for purchase or none at all. It’s as if states dictated that you had to buy a Mercedes or no car at all

And

Since leaving office I’ve written about public policy from a new perspective: outside looking in. I’ve come to realize that protecting freedom of choice in our everyday lives is essential to maintaining a healthy civil society.

Why do we think we are helping adult consumers by taking away their options? We don’t take away cars because we don’t like some people speeding. We allow state lotteries despite knowing some people are betting their grocery money. Everyone is exposed to economic risks of some kind. But we don’t operate mindlessly in trying to smooth out every theoretical wrinkle in life.

The nature of freedom of choice is that some people will misuse their responsibility and hurt themselves in the process. We should do our best to educate them, but without diminishing choice for everyone else

This article is mostly about the sub-prime stuff…but it is one that, hopefully, all of us can agree on…

http://online.wsj.com/article/SB120485275086518279.html?mod=djemEditorialPage

44

[QUOTE=Unregistered;17252]you say:Wow, now your getting interesting. My mother in law had Alzheimers for 6 years before she died. So exactly when would you like for me to pull the plug on her?

. How about people who don’t even want dialysis, but whose families want them to have it?

So your answer is just to have Daschle (or someone like him) decide? Interesting.

[/QUOTE]
You’re missing the point, Unregistered. I wasn’t giving ANY answers–just posing questions. And the Alzheimer’s situation wasn’t to “pull the plug” on someone with Alzheimer’s (they don’t have a plug, only people on life support do). The question was whether to start dialysis on someone who was already in the severe throes of a terminal illness.

45

[QUOTE=Unregistered;17253]Why do we think we are helping adult consumers by taking away their options? We don’t take away cars because we don’t like some people speeding. We allow state lotteries despite knowing some people are betting their grocery money. Everyone is exposed to economic risks of some kind. But we don’t operate mindlessly in trying to smooth out every theoretical wrinkle in life.

The nature of freedom of choice is that some people will misuse their responsibility and hurt themselves in the process. We should do our best to educate them, but without diminishing choice for everyone else[/quote].
The reality is that medicine is fundamentally different than other types of commodities, and “choice” is deceptive in this context. When we’re sick, we want to be healed. That involves a relationship with a caring and knowledgeable person who presumably wants to heal you. Sometimes healing (cure) isn’t possible. In that case, you want supportive care that will allow you to minimize symptoms and live as fully as possible with fewer bad days and more good ones. Or, if you’ve outlived every healing effort we have, perhaps your goal is a good death.

The amount of knowledge it takes to get through medical school, through a specialty, and then to keep up with the tens of thousands of new journal articles that come out each year is absolutely beyond the “consumer.” We rely largely on doctors to communicate our options to us–but for the most part they haven’t been trained in presenting options, and may not even speak our language, either literally or figuratively. It takes a n enormous amount of effort and support even to formulate the questions to ask–let alone to find the right answers for yourself. That means that true, informed choice is rarely possible.

Healthcare isn’t primarily about technology (MRI vs. PET vs. CT scans). IMHO, it’s about making good lifestyle choices to minimize the chance of preventable disease or injury, avoiding tertiary complications if you DO get a chronic illness, and coordinating care to reach the best outcomes for the lowest costs.

46

Done, except I refuse to write to Roland Burris. Hopefully I’ll be able to contact a successor soon. However, if he’s still in office in May when I go to DC, I’ll have to shame myself by setting up an appointment.

47

You asked for answers to your questions and I said:

My mother in law had Alzheimers for 6 years before she died. So exactly when would you like for me to pull the plug on her?

Ok, I confess, I was being a little sarcastic in my response because of the carelessness of your remark: “People with other terminal illnesses, like Alzheimers?” In the context of dialysis, of course there is a plug to be pulled. And, no, death is not immediate, but it is certain.

I would lean toward the no dialysis position in the severe throes of terminal illness situation.

But on a more serious note. We are probably agree on some things. First, let me share my experiences.

I’ve been on PD, HD and had a successful transplant (and still counting). I found In center HD horrible, but I wasn’t on it long, switching to PD. PD was ok, but not great. As my very fortunate luck would have it, just as my PD was getting less effective and the talk had turned to HD I got a cadaver transplant. A lucky day indeed, for me at least.

Now looking forward. I have had high hopes that nocturnal would be sanctioned and that going on it (given whatever other issues are going on) would be a viable choice.

I see a lot of talk…but little in the way of action from CMS. Everyone talks about the horrible mortality rates, the left ventricular hypertrophy, the horrible quality of life scales.

Then I read about the reimbursement rates going down over the years. The focus on squeezing every penny out of the dialysis provider (and I wonder how that impacts the number/quality of Drs. going into Nephrology). And I read how dialysis takes a large share of Medicare dollars.

There are many reasons why people want national healthcare, and many why people are dubious.

But, do you have any specific reason why you think national health care would better than the current situation for the dialysis patient?

48

Hi Folks

I lost this a while ago, wasn’t sure if it was on dialysis. Or was it about some new things heading down the road as a whole. As far as dialysis and the what we have now is a system that is messed up. Will it get better, we have wait and see, things might not really change for sometime. if things get worse for those on dialysis we have NKF and the other so called dialysis consumers groups to thank for not looking out for the rights of those on dialysis. Plus we have ourselves to thank, although as a single voice our whole system isn’t set up to hear on single person crying in the woods

thanks

Bob Obrien

49

Hi Unregistered,
No doubt there’s national health care – and national health care. But from what I’ve seen in terms of a move toward better use of health information systems, and at least lip service to patient-centered care, I’m hopeful that eliminating the profit motive from insurance providers might better align the interests of the payer (Govt) and payees (all of us). For example, Kaiser Permanente in Southern California has had a “Home First” program for CKD for several years now. They identify folks who are at risk for CKD through lab test results, send them a letter, and offer them two-stage education (early on to slow progression, and later for options choices). Their attitude is that in-center HD is a treatment of last resort–there needs to be a good reason why someone can’t do any form of home treatment before it is approved. (Other insurers are moving to this as well, because home treatment tends to reduce costly hospitalizations).

Kaiser still doesn’t have a lot of folks dialyzing at home, from what I hear. But the beauty of their approach is that it’s coordinated based on information, and they don’t have the “Part A/Part B Wall” that is built into Medicare. Kaiser gets a capitated, per-patient fee. They make money by keeping people healthy and out of the hospital. So, they are motivated to do what they can to maintain health. This is what a national healthcare system could do.

It’s really critical to keep in mind that 75% of healthcare costs and 75% of deaths are due to chronic disease. Most of the so-called “horror stories” about slow access to care in countries with national healthcare systems relate to elective surgeries or acute health problems, which are less than 25% of healthcare. We need to focus on the biggest problems, and, quite frankly, the low-hanging fruit.

50

Dollars to doughnuts diagnosis
The only way a doctor can do a good job and still make a living is to reject insurers.
By Albert Fuchs
April 16, 2008
Imagine one morning you’re craving something sweet, so you stop by the corner doughnut shop. Turns out the wait is half an hour, the clerk is rude and, when you finally get it, the doughnut is stale. Would you buy doughnuts there again? Of course not.

Yet, every day, millions of Americans put up with just that kind of service in their physicians’ offices. And they keep going back.

Anyone who has visited a primary care doctor lately knows the drill: You show up on time, only to wait 45 minutes or even an hour. In the examination room, the physician (who offers no apology) seems distracted, harried and eager to get to the next patient. Then you’re referred to a specialist – who doesn’t have an opening for a month.

Every politician and his Aunt Martha has a scheme to overhaul American healthcare. But not one of them will solve this problem: Most doctors are awful at serving their patients. The typical hair salon pays more attention to customer service than the typical doctor.

Why? Even the best medical schools give short shrift to practice management. So a doctor can emerge as a skilled diagnostician without a clue how to run a business that serves consumers. In fact, many physicians find it distasteful to think of medicine as a business at all. They feel that it’s their mission to serve as many patients as possible rather than to provide the best care possible. Most significant, today’s doctors are preoccupied with the bureaucracy of insurance companies, so much so that they’ve lost the simple logic of the doughnut shop model.

To be sure, physicians are not entirely to blame. With insurance companies dictating how much doctors can charge for services as diverse as a routine checkup or an appendectomy, a doctor has only one route to more income: increase volume. I know. When I began my own private practice in internal medicine, my volume grew quickly, and so did my work hours. I didn’t complain because I took that as a sign of success. But before long I found myself toiling nights and weekends just to keep up with the volume. First I sacrificed my free time to my practice, then my sleep and finally the quality of my practice itself.

From an economist’s point of view, my problem was simple. I was making good doughnuts and selling them below market price. I was earning a good living, but I couldn’t sustain that level of production. So I took action. I dropped an insurance plan – the one that gave me the least compensation. Almost immediately, I had fewer patients but more time and energy for those I maintained. When my patient ranks swelled and I got too busy again, I dropped another plan. This continued until I reached the right balance of time and patients.

For more than a year, I haven’t received a single dollar from any insurance company. I work for my patients. A few hundred doctors across the country are working the same way, some in blue-collar towns. Routine care should be affordable to the middle class, and as more doctors and more patients form relationships that exclude insurance companies, prices will drop. Insurance doesn’t make routine care affordable; it makes it more expensive by adding a middleman. I know that some patients can afford nothing, so two afternoons a month I volunteer at a clinic that cares for indigent patients, which I could not have done with the huge patient volume I was seeing a few years ago.

When doctors break free from the shackles of insurance companies, they can practice medicine the way they always hoped they could. And they can get back to the customer service model in which the paramount incentive is providing the best care. Only then can doctors reclaim the simple dignity of any businessman: These are my doughnuts; only I and my customers can determine their worth. (At the end of each week, I will donate some to the needy, but I will not let a third party set the price.)

And when patients are the customers, doctors will listen when they ask for services not on the insurance company menu. If an urgent need arises after hours, patients want to be able to call their own doctor. Patients want to be able to e-mail their doctor with non-urgent questions and to fax them interesting articles. They want to be educated, not just medicated. They want to know they can get in to see their doctor the same day if needed, and that their doctor will be the one taking care of them if they are hospitalized. If doctors had fewer patients, meeting all of these needs would be easy.

How many customers would have to request rainbow sprinkles before the doughnut shop owner kept them in stock?

Albert Fuchs is an internist in Beverly Hills.

51

Hi NDXUFan12,

So-called “managed care” really hasn’t done a good job. Neither has insurance. So, the idea of doctors caring for patients–leaving out the middle man in between that sucks huge numbers of dollars out of the system without actually providing any care–is very compelling. Doctors aren’t very good at running businesses; they would need help with that. But what we have now just doesn’t work.

52

What this doctor writes about is so-called a “boutique” practice.

How many dialysis patients do you think could afford to pay-out-of pocket 100% of the charges a “boutique” dialysis clinic would charge if it charged what some large dialysis corporations are currently charging commercial payers? I’ve heard figures of $1,000 a treatment for dialysis alone…which would be $156,000 a year at 3 HD treatments (or equivalent a year), more for 5x weekly treatments.

Before Medicare covered dialysis, patients who couldn’t afford dialysis were given medication only and they died. Medicare was extended to cover workers and spouses and children of workers in 1973 because of lobbying efforts by patients and organizations, like the NKF. The pitch Congress was given was that many working-age people would work to pay back into the system that was supporting their care. This goal hasn’t been realized for a number of reasons, including but not limited to these:

  • changing demographics of patients on dialysis
  • dialysis care that doesn’t allow people to feel healthy enough to work
  • dialysis settings that aren’t flexible enough that patients can do dialysis there and still work
  • patients being uninformed about treatment options other than in-center HD
  • controlling and uninformed staff who don’t believe patients are smart enough or care enough to be in charge of their treatment and their lives.

I have talked with people from other countries – England, Canada, Netherlands, France, Germany – where government supports healthcare for its citizens. All were satisfied with the care they receive. None said they waited excessively long for needed healthcare. No one complained that their healthcare system was worse than ours. And all had healthcare when they needed it.

I have also gotten the emails from loved ones of people in countries where dialysis is only available for those who can afford it and their loved ones will likely die as it was in the U.S. prior to 1973. Would anyone on this message board suggest the government should not provide funding for dialysis so they could go to a doctor who practices “boutique” care?

Our healthcare system needs reform. Here’s information I copied and pasted from the World Health Organization’s 2008 report entitled Primary Health Care. In it the WHO recommends 4 types of reforms. We might want to consider them in reforming our healthcare system.

[I]* reforms that ensure that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection – universal coverage reforms;

  • reforms that reorganize health services as primary care, i.e. around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world while producing better outcomes – service delivery reforms;
  • reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors – public policy reforms;
  • reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems – leadership reforms.[/I]

http://www.who.int/whr/2008/whr08_en.pdf