• Death Panels in Oregon

    The WSJ editorial page is back today, with warnings of DEATH PANELS! in Oregon:

    Liberal states often preview health-care central planning before the same regulations go national, which ought to make an Oregon cost-control commission especially scary. On Thursday a state board could change Oregon’s Medicaid program to deny costly care to poor patients who need it most.

    Like most such panels, including the Affordable Care Act’s Independent Payment Advisory Board, the Oregon Health Evidence Review Commission, or HERC, claims to be merely concerned with what supposedly works and what doesn’t. Their real targets are usually advanced, costly treatments. That’s why HERC, for example, proposed in May that Medicaid should not cover “treatment with intent to prolong survival” for cancer patients who likely have fewer than two years left to live. HERC presents an example to show their reasoning for such a decision: “In no instance can it be justified to spend $100,000 in public resources to increase an individual’s expected survival by three months when hundreds of thousands of Oregonians are without any form of health insurance.”

    The piece then goes on to rail against Medicaid, and HERC, for trying to limit what Medicaid will cover.

    First of all, I’m always a bit confused by the fact that it’s often the same people, and organizations, who rail against rationing within Medicaid while simultaneously railing against the Medicaid expansion. Evidently, they are fine with completely denying Medicaid to many of the poorest among us, but against making Medicaid less robust once they get it. Odd.

    But my larger concern is one of philosophy. We simply cannot afford to pay for everything. We must own that. And so, there will at some point have to be discussions as to what we might not pay for. Unlike the editorial, I will link to the actual HERC document that discussed this question. After laying out the proposal, the recommendations of the committee were as follows:

    HERC Staff Recommendation:
    1) Discuss general framework of THERAPIES WITH MARGINAL BENEFIT AND/OR HIGH COST

    Therapies prioritized lower include those with:

    i. Marginal or subclinical benefit,
    ii. Very high cost in which the cost does not justify the benefit, and
    iii. Equivalent efficacy to a therapy prioritized higher, that are significantly more costly.

    Additional specific therapies considered to be prioritized lower are those found by the Pharmacy and Therapeutics Committee to be of marginal benefit and/orpoor cost-effectiveness found in Table XX located at www… (e.g. as of October 1, 2013).

    I wish we never had to have these discussions. I really do. But at some point, we probably should think in terms of prioritizing therapies. This isn’t the worst way to do it, and at least it’s in public.

    I’d like to make a larger point. Although the editorial makes the case that this is the left’s one-size-fits all approach, that’s just not true. This is a discussion of Medicaid, not of Medicare, and not of private insurance (which also refuses to cover things, about which the WSJ doesn’t seem concerned). No one is prohibited from spending their own money on futile care. No one is prohibited from buying an insurance policy that will continue to cover futile care. What’s being discussed is how we will use taxpayer money to cover those at the lowest end of the socioeconomic spectrum. Recognize that anyone that qualifies for Medicaid will not be able to pay out of pocket for these services. Recognize that they will never be able to afford private insurance that covers these services. Recognize that we will never approve subsidies that will allow them to cover the services or private insurance that does. So either the government does, or no one does.

    Have that debate. Have it in public. Have it civilly. But please don’t pretend to be outraged by that serious discussion while simultaneously being ok with denying much more to many more in the name of “fiscal responsibility”.


    • As you note, this is just the latest attempt at false umbrage to try to fool people into believing the US health care system doesn’t already ration care. Any attempt by our health care system to foster transparency concerning the mechanisms it uses to make decisions about what to cover with its finite resources leads to it getting hammered by the WSJ and others for limiting freedom.

      However, states setting rock-bottom income eligibility limits for Medicaid is rationing; 50 million uninsured is a consequence of rationing; as is a Medicaid patient only being able to schedule an appointment on Wednesday mornings between 9-11.

      Beatrix Hoffman covers this territory well:

      • Exactly. I do not understand why those opposed to some sort of cost-effectiveness approach to health care, similar to Britain’s NICE, do not get this point. Resources are limited. Our choice as a nation is to maximize these resources on those who have insurance as opposed to maximizing the number of people insured and limit some choices for those with insurance. Both are decisions which include rationing care. However, it is easier politically to say once you have care nothing should be rationed.

      • I am fine with putting the squeeze on Doctors income – but am not sure that is a big “prize” – even Docs have moved some of their income stream from fees to services [ownership interests in labs/scanning/hospitals]. And I am not sure it is correct – or a good idea – to think of the uninsured as a homogeneous group – many of them are happily healthy and uninsured – which is there right at this point.

    • You say that nobody is prohibited from spending his own money on “futile” care. First of all, all care is futile in the sense that we will all die, and a person has the right to spend millions for 3 more months of life. There are people who spend that much on a dog, for chrissake!

      Second, a person who is forced to pay taxes lifelong for Social Security, Obamacare, Medicare and Medicaid will be deprived in old age of “his own money” that he could have had available to extend his life. It should be his choice. A simple calculation will tell you that all those taxes, if invested at a young age, would yield a fortune in excess of $5,000,000.

      • No one spends $5,000,000 for Medicaid, which is what we are talking about here. If you paid that much in taxes, you’re too wealthy for Medicaid. And, you’d be covered by Medicare, so this would be moot.

      • I assume this “everyone dies, therefore healthcare is futile” argument is a joke. On the small chance that it’s not, please realize that no serious person believes the goal of health care is to make people immortal. It’s designed to prolong life quantity and/or quality, as the case may be. People happen to be willing to pay for that, voila, health care industry.

        On the second, apparently serious point, realize that the taxes paid and benefits received are highly dependent on one’s earnings history, and that medical needs are highly independent of one’s earnings history. Nonrecognition of those two facts makes a “simple calculation” impossible, and strutting about with promises of fortunes terribly misguided and inaccurate at the very best.

      • I feel like you are thinking about it backwards. The social safety net, largely as it applies healthcare, is not an investment but a social contract. I pay into the program to help to care for my elders and in return the next couple of generations younger than me will pay their part for my care in the future.

        We are a society and this is what a society does. It’s what helped us evolve past nomadic tribes.

        Also, I take great issue with your initial logic. It’s true that in the long run we are all dead. Why does that have any effect on the quality of our lives? Or the quality of our society? Heck, if we are all going to die why even bother trying?

      • It’s not a matter of we all sooner or later die; it’s a matter of can the people in need die without pain and suffering, and to die with dignity!

      • Jimbino, the point of Social Security taxes is not to provide benefits to the payers. Those revenues go out to current retirees. So the purpose is to help make sure that current retirees don’t fall into poverty and that current workers don’t go bankrupt supporting them. Consequently, it’s misleading to calculate how much a worker would have if that worker’s own Social Security contributions were saved and invested, because that’s not how the system works. (If workers started doing so today, then current retires would be without benefits.)

    • The Oregon prioritization process is a brave and thoughtful experiment in finding how to prioritize care so that it is done in an ethically correct, sensitive, and publically acceptable way.

      The HERC committee is composed partly of physicians, but is balanced by others: http://www.oregon.gov/oha/OHPR/pages/statutes.aspx#health_evidence_review_commission__herc_. That’s not a “death panel.”

      HERC should be thanked.

    • You should always mention the most pervasive form of rationing in the U.S. health care “system” – instead of a ration card, access is determined on the basis of the size of your bank account. The 50 million un/under-insured – or is it 75 million now? – can explain how rationing works on a practical, fatal basis.

      • Dick Cheney jumped to the top of the transplant list, bumping others who had been on for years. Of course it had nothing to do with his position and wealth.

    • “Futile” care is not always so easy to recognize. Of course there are circumstances when it is obvious and in general nobody wants futile care. The trouble is that people are not statistics and probabilities. Even when a treatment extends survival several months on average (which by the way can be very meaningful to folks), some individuals may get many years of life. The median does not tell the whole story – at all.

      When we are young and healthy, we all think that if we get advanced cancer, we would not want chemotherapy that extends life a bit. But our perspective changes when we are ill. And we are all in this together. Those who are ill today likely paid in for Medicaid and Medicare through taxes over a life time.

      So spare me the “we can’t afford everything” talk that only sounds good to someone who can’t even conceive of actually needing care. Try to put yourself in the shoes of someone fighting for survival faced with a serious illness before you speak. Being on the short end of the “we can’t afford it” stick is something I would not wish on anyone.

      The ill are the most vulnerable members of our society. Let us judge ourselves by how we treat those who are most vulnerable.

      Finally, I think it is worth noting that the core problem is not that we have poor people or that people want treatment when they are ill. It is that care is too expensive. We should get serious about fighting for the cost of health care to come down so that we can afford to take care of everyone. It is a false choice to accept that health care is expensive and then deny it to those in need because it is.

      • Tom B…

        I wonder what your standard is when you say care is “too expensive.”…

        I think we have dealt with this before on TIE – one person’s “expense” is another person’s income. The flow of dollars is from those who need to those who do – with a bit of paperwork in the middle.

        The only way I know of that health care costs less is if someone makes less money – has a lower profit or lower income. Who would you suggest we put the squeeze on to drive down the cost of health care?

        • Doctors, of course!

          But I’ll even throw you a bone. Let the market reduce doctor pay by limiting the power of the AMA to restrict the practice of medicine by among others immigrant doctors, nurse practitioners, pharmacists, etc.

          But of course, society should also fund the training of a lot more primary care doctors and nurse practioners.

          • You may want to take a look at where the money is being spent before recommending solutions. Then follow Willie Suttton’s advice… You will find that doctors compensation is not a great opportunity for savings. Maybe some, but not great, especially if the goal is to attract more people to the field. Physician compensation is not much higher in the US than in Canada or Western Europe.

            It would be wiser to focus the analysis of this problem by understanding which dollars improve health and which don’t and focus on the latter. Administrative overhead is enormous in American healthcare. We employ armies of people who fight with one another over payments, approvals, etc and additional armies who code, bill, process things, etc.

            Pricing is non-transparent and not linked to value. Treatments could be priced according to the amount of benefit they provide – like many other products and services – but they are not. Cancer drugs that provide marginal benefits are just as expensive as life saving ones.

            The reimbursement system makes efficiency and innovation in care delivery very difficult. In today’ssystem, we pay for a visit or an operation. If the same care could be delivered cheaply via Skype, phone, or email, this can’t be done because it is very difficult to bill and to deliver care like this in a HIPPA compliant manner. There is much that can be done about cost by getting serious about those costs that do not deliver better health.

            Real improvement will require looking beyond today’s framework and courage to really change how we do things. If we do that, it does not need to be a zero sum game as some in this conversation think.

      • The quote from the WSJ piece is misleading if not counterfactual. The current guidance for late stage cancer care applies to people with expected life of 24 months or less, that guidance was adopted in 2009. HERC is considering changing that language to something that doesn’t reference expected life. And historically, what was in place prior to 2009 was even more restrictive than what they have now. Oregon has been loosening restrictions over time, not tightening them.

        Determining coverage and doing so fairly is a serious and difficult issue. The public dialogue surrounding this decision (and I have more in mind than a WSJ editorial) hasn’t come close to doing it justice.

    • I find my self in violent AGREEMENT with Aaron…

      Which is not the norm – we usually are in very different places…

      My strand of Libertianism holds…

      1. That I should be free to spend as much of MY resources as I choose on whatever futile or expensive or unproven or whatever treatment I want.

      2. It is irresponsible of me to spend the resources of OTHERS without considering some sort of cost/benefit calculation.

      I think it is very important to remember that what Oregon is trying to work on is MEDICAID – not Medicare. As Aaron correctly points out Medicaid is not meant to be even equal to what is available via private insurance. It is meant to be a safety net – providing some minimal coverage USING OTHER PEOPLE MONEY.

      I do believe ther us a lot waste in Medicaid and would like to see it rettoled to focus on providing quality care for chronic conditions. But in general I am OK with the concept of a safety net type of program that helps those most in need of our help – – but I doelieve any program will have to have limits to be sustainable.

    • I have been studying large claims in Medicare. What I find is that on a typical $200,000 paid claim, about $90,000 goes to drugs and devices,
      $100,000 goes to the hospital, and $10,000 or less to the surgeon.

      This has led me to conclude that before we ration in any insurance program, we should be sure that large claims are cleared of price gouging.

      If we do that, then harsh rationing is less necessary.

      Any one interested in my research, feel free to contact me.


    • Seems to me the solution is simple:

      Increase coverage so that every conceivable treatment is covered, with no deductibles, co-pays, or limits of any kind.

      Then make sure no one qualifies for coverage.

    • From the WSJ: “Like most such panels, including the Affordable Care Act’s Independent Payment Advisory Board, the Oregon Health Evidence Review Commission, or HERC,

      ***claims to be merely concerned with what supposedly works and what doesn’t.***

      Their real targets are usually advanced, costly treatments.”(asterisks mine)

      Does HERC state that one of its purposes is to ration care?

      That should be the focus of the issue though other issues exist. Is HERC being honest in what it is doing? Is it non political? Is HERC moving certain diseases up and down a list because of political pressure?

      Rationing has always existed and always will as life involves trade offs that occur continuously.

    • I agree with the lonely libertarian but I will go further in that I think that both Medicaid and Medicare should refuse to pay for all treatments that do not have strong convincing evidence of positive outcomes. The directors of the programs should also mostly refuse to pay for treatments that fail.

      One of my pet peeves is this idea that people paid for some specific benefit through the payroll taxes. No such agreement exists. We are taxed (we do not pay in order to get some benefit) to pay whatever the majority of voters working through our corrupt politicians decide we should get at the time! It is a tax plain and simple. SS and medicare are welfare programs same as TANF and SNAP plain and simple.

      I think that this:

      I’m always a bit confused by the fact that it’s often the same people, and organizations, who rail against rationing within Medicaid while simultaneously railing against the Medicaid expansion.

      Is a bit unfair because it is not the same people but to groups in a
      against the ACA. The 2 groups lets say conservatives and medicare recipients have different reasons for not liking ACA.

      • The cynical part of me says that if we go down the path suggested by Floccina we will not have much of a problem – much of what we are paying for today has little or no evidence of a real benefit – the latest example that we have seen documented are wellness programs. Add in the substance abuse programs Obamacare includes and some of the “preventative” programs that do not really prevent a lot goes away. Then there are chiropractors and such…

    • I think conservatives believe that we shouldn’t make people too dependent on the government, but if we do have people relying on the government for dear life, then we shouldn’t let them down by denying care just because it’s too expensive. If we choose to not have the government make a healthcare program, that’s one thing, but having taken responsibility for someone’s health and life, we should keep them healthy and alive as best we can.

      On the other hand, conservatives would be fine if you gave people a voucher to pay for their own care, because then they have responsibility for their health, so if they find a treatment too expensive, that’s their decision.

    • The ethics applicable to end-of-life healthcare are profoundly difficult to balance. The process is routinely troubling to me as I interact with my patient, their family, the complexity of colleagial team-work and the institutional realities involving resources. Beneficience, futility and dignity are recurring themes.

      Sadly, there is no widely respected and nationally sanctioned institution to foster the national priorities for our nation’s investment in the healthcare industry, especially at the end of life. Such an institution will be necessary as we grapple with the realities of our nation’s economic autonomy within the world-wide community. In 2010, 45% of our nation’s healthcare resources come from the federal, state and local governmental levels. (Medicare Office of the Actuary annual reports) Having institutions that manage the economic mandate for healthcare also manage the social mandate for healthcare seems to be a colossal conflict-of-interest. For any physician attempting to offer a long-term relationship as a basis for Primary Health Care, this issue by itself is the most demoralizing aspect of professional survival.

    • I am surprised that people take WSJ editorial pages seriously. A few days back they were on a rant about monetary easing and inflation after their paper published a thoughtful study on how the inflation doves had it right for the most part. They are sure that any liberal position is wrong and evidence be damned. I stopped my subscription.

    • Typo:

      “Evidently, they are fine with completely denying Medicaid to many of the poorest among us, but against making Medicaid MORE robust once they get it.”

    • This discussion is in some ways unique to the US. Almost all other developed countries have some version of government run healthcare system. These system are all significantly less expensive than the US system. One significant reason for this is the priorizations taking place at every level. Expensive drugs are prescribed only by specific experts, there are wait times för many procedures etc. Taken together these systems provide health outcomes for their populations vastly superior to the US system.

      The reasons are many: research based treatment plans, enrolment of all newborns into pediatric programs, etc. As the system is responsible for the outcomes and costs it tries to optimize on these aspects. The only way to manage costs in a system where the consumer is not paying (given fixed costs), is through limiting access. The trick is to do it intelligently. There is ample evidence that this can be done.

    • actually- mr. carroll, there is ample regulation preventing people from spending their own money on what you define as ‘futile’ treatments… if the hc service is covered by the plan (particularly medicare and medicaid, but not exclusive of private plans) — the provider is PROHIBITED from receiving payment for the service if it is not authorized…

      your arguments do not hold up –medicaid recipients can often afford some treatments for which there is little 100% proven benefit– i.e.. much chiropractic care and ‘alternative’ medicine — and they will swear it is very helpful to them…

      so, I am fine with you making stipulations about the hc policy debate, but you cannot do it unilaterally inaccurately and expect agreement

      • But this is saying Medicaid won’t cover it. That leaves people to pay for it themselves.

        • Which is as it should be IMHO…

        • But you have stated that people on medicaid cannot pay for any healthcare…

          ” Recognize that they will never be able to afford private insurance that covers these services. ”

          clearly, many CAN afford to pay for some healthcare services… either these patients are being driven to ‘alternative’ care because ‘standard’ or ‘usual’ or ‘accepted’ care is not available under medicaid (either not covered well, or incompletely, or no access for whatever reason)… or it has not worked… or they are not familiar with it, or they do not want it…

          I just think you are perpetuating a fallacy to stipulate that people on medicaid cannot afford any covered services…

          I would also add that simply because a study suggests that there is little benefit for a particular service or treatment, it certainly does not mean that individuals do not, or will not, benefit greatly…

          another point- you did not respond to my criticism that you have incorrectly stated current policy about spending one’s own money for covered services… (section 4507 of 1997 balanced budget act put it into statute for Medicare patients, for example)…

          and one more 🙂

          it would seem that those who make the policy on what should be an essential covered service for low income Americans ought to be willing to live under the same benefit packages… it would make them a lot more thoughtful and caring about the damage their policies can wreak through both unintended, and intended, consequences… note how the President intervened to give congress a ‘get out of jail free’ card on the plain language of the ACA— those 11,000 are not eligible for ’employer sponsored health insurance’ per the law — and no other business in the country is allowed to use pretax dollars to purchase insurance… and that was clearly not the intent of the statute, to exempt congress and staffers…

          If Oregon bureaucrats really believed in their program, they ought to be willing to live under it…

          • On Medicaid? Today? You really need to meet some people on Medicaid. Most of my patients would be troubled by a $10 copay. There’s very little in the way of services that they can pay for.

            • It is understood that many of the people on Medicaid might have difficulty raising $10, but we cannot forget that though a person is on Medicaid many have more assets or access to assets than many people imagine.

              I don’t generally like anecdotes, but I have experienced too many of them in this area to not draw a conclusion. We have to do a much better job so that those that cannot truly afford the $10 don’t suffer because of those that can.

              Two examples of many that demonstrate we have a problem that can easily be seen and thus remediated.

              One person I know personally drives a new Lincoln SUV, recently bought a new expensive home, takes cruises, eats out frequently, etc. The life of an upper class individual feeding off of Medicaid.

              The craziest one I have seen spent about $30,000 on cosmetic plastic surgery and though told by the physician that Medicaid was not accepted in that office refused to pay the $7 co pay.

              We cannot continue to ask other people to pay ever increasing amounts of money to a group labelled as needy that contains so many abusing the system. Those that support such policy, and I am one, should spend at least as much time on that problem as the time spent trying raise capital to support those in need. We wouldn’t have to raise so much capital and could possibly increase Medicaid services (decreasing the risk of denial of needed care… rationing) if we focused more attention on this problem, but politics gets in the way. That is one of the dangers of a political solution..

          • In other words, you do not believe destitution exists in the United States; at least not enough to make it impossible to find a doctor somewhere to provide care (because there is no bottom to the cost of care?). But, in the event that it can be proven to you otherwise (say a destitute person is shoved into your presence) then “choice” is the alternative explanation for their not getting privately paid services to get care not covered by Medicaid… another way of saying “no” they can pay for it.

            Of course, this is couched in a “many not all” statement to obscure the essential non-logic of that idea with an ambiguous quantity. To paraphrase “Not all people on Medicaid have only Medicaid as a resource. MANY don’t.” So, these many also give rise to? An exaggerated cost to society for people partly able to pay for care? Then why give them Medicare at all? The insinuation that there are innocents in that number, but too small to count or consider?

            That doesn’t reconcile with the second idea that the bureaucrats should “live under the system.” We should expand the experience of destitution from those true few? Or at least pretend that we are? For what end result? The shared experience? Empathy? To expand services via Medicaid for “many” people who were already mentioned to have means to procure it themselves? The entire exercise is to help mitigate the negative parts of being on Medicaid and to reduce cost. It does not make sense to assert that many choose not to use Medicaid and have the means to go elsewhere and simultaneously object to Medicaid trying to cut costs on those same people who already go elsewhere.