SMOKE AND MIRRORS: THE HEALTHCARE ACT VANISHING GAME

The American public is frustrated. Congress has its lowest approval rating ever. And they just can’t seem to pass a healthcare bill. The only surprise is that anyone’s surprised, and even that should come as no surprise. Let us gaze upon the elephant(s) in the room:

First, almost everyone hates the do-nothing Congress but continues to elect the same career politicians over and over again, pointing the finger at “the other guy.”

Second, everyone wants healthcare reform unless it involves rescinding expanded benefits that the prior legislation meted out.

Third, everyone wants laws that require emergency rooms to provide urgent care irrespective insurance or ability to pay (that’s what a compassionate society does, right?) but no one wants a mandate to purchase health insurance.

Beginning to see a pattern?

Congress can’t fix a system that needs a major overhaul in both the way we think and the way we conduct business until we accept the fact that we need to overhaul the way we think and conduct business. A politician’s lifeblood is votes. Everyone accepts the need for increasing efficiencies and trimming waste and fraud in healthcare, and many embrace increasing competition in the insurance marketplace. Some are convinced a single-payer system is the answer (see below). But it will not be enough. The burgeoning ranks of the elderly infirm with fewer workers to pay for their care doom any of the current plans to failure. For any clear-thinking healthcare worker the trajectory of premiums for Obamacare was inevitable from the day of its conception. Gravity says you go down, and the laws of economics say, “You don’t get sumthin’ for nuthin’, as much as wishful thinking tries to obscure this truth. With bunsiness as usual, the many hidden taxes in Obamacare were insufficient to sustain the mandate of covering all pre-existing conditions and extending insurance for “minors” until age 26, on top of providing mandated non-essential care. And it’s only going to get worse.

What’s the answer? Health care rationing, otherwise called “death panels” by those that want to quash any reasonable discussion of the topic.

We’ve always had covert rationing (shhh!). Anyone who thinks a homeless street person gets the same level of care as a movie star or professional ballplayer (or Congressperson, for that matter) is living in a fantasy world. That being said, the excesses in the U.S. system are more enormous at all levels of care than most people realize. I will illustrate with a single example: At a recent meeting I attended there was a discussion about the suitability of placing an artificial valve in a patient that had a critical narrowing of the exit valve of the heart, otherwise known as aortic (valve) stenosis, which kills someone within 1-3 years of onset of symptoms. Until a few years ago, the only treatment was an open heart operation, but innovative minds developed a procedure to place a valve inside the old, calcified valve via an artery without surgery, known as transcatherer aortic valve replacement, or TAVR. This particular patient was in her late 60s to early 70s, had advanced alcohol-related liver disease (but was no longer drinking), and had begun to show signs of reduced blood clotting and fluid accumulation in the belly known as ascites related to her diseased liver. Although her life expectancy from the liver disease cannot be precisely predicted from the information I have, it is not unreasonable to postulate 3-5 years. Her aortic valve disease would probably kill her within 1-2. She was deemed a high risk surgical candidate so is being triaged to TAVR. It is more difficult to find the average cost of the procedure doing an Internet search than a cost-effectiveness figure ($50,000 is considered the benchmark for qualitylife-years gained, or QALY, originally based on hemodialysis figures), but $52,200 ± $28,200 is the estimate I found, representing a purported net loss for the institution (as opposed to surgical valve replacment which supports a net gain). Assuming that this patient has no complications (likely, but certainly not guaranteed), you will reduce her short term risk and improve short term quality of life significantly. However, you now have a patient with another terminal illness (end-stage liver disease) at even higher bleeding risk due to the aggressive antiplatelet drugs needed to prevent valve clots, who will likely live longer to be in and out of the hospital in her final years to palliate her progressive liver disease. (Of course, it is possible that the medications could shorten her life, as liver patients are prone to bleeding for many reasons.) Now extrapolate this example across the country and across different illnesses and medical specialties, and you’ll begin to get a sense of the magnitude of the problem.

So, are these doctors greedy, incompetent, or stupid? Absolutely not. A terminally ill patient with advanced cancer and low life expectancy would never come up for discussion. However, that large (and growing) senior population with serious chronic illnesses we’ve become so proficient at eking every last ounce of life from is a much more difficult decision for doctors. Often, they feel that societal issues should not come between the physician and the patient, and everyone is loathe to place the responsibility for these tough decisions in the hands of the government. The upshot of all this is that we’ve abdicated the responsibility to address this overtly. And no wonder: Opening oneself to the criticism of being an uncaring bean-counter is no more appealing to a physician or layperson than to a politician seeking reelection.

So what can we do?

We can set up committees made up of doctors, clergy, citizens, social workers, economists, and yes, politicians to examine clinical scenarios and/or actual patient cases and determine suitability and feasibility of a particular high-cost interventions, adding into the equation societal and fiscal constraints. (There are those that believe a single-payer system will solve the system’s ills, perhaps by overtly or covertly addressing this; I’m skeptical, but the debate is beyond the scope of this rant). This independent committee approach unburdens the caregiver of the responsibility for factoring in issues extraneous to the patient. However, this concept will not be well received. Consider the outrage engendered by recent British government intervention in its decision to prevent a high risk procedure on an infant afflicted with a congenital ailment. Although in this case I agree with the critics, as it was reported that the funding was obtained by the family from private sources, there are other high-profile examples of widespread censure of attempts to limit life-giving care in patients with poor prognosis (i.e. Karen Ann Quinlan and Terri Schiavo, to name a couple).

So what will we do?

All indications are that we will continue to posture, discuss repealing and replacing or modifying Obamacare, and either do it or not. For me, it doesn’t matter. Without fundamental changes that I believe the American people, at this time, are unwilling to accept, the downward economic medical spiral will persist. The forecast is for increasing debt paralleling that of the greater economy (of which healthcare comprises 18%). Like a junkie needing greater and greater cash infusions, it will need to hit bottom before it changes.

I know this is a pretty grim, some might say pessimistic, prediction. And there is always the chance that the exponential advance of technology may save us by completely changing the face of medicine. Unfortunately, we don’t have a lot of time.

The truth is, elephants in a small room make quite a mess.

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