• Rationing exists – ctd.

    I’ve been getting a lot of interesting comments and emails about my last post. Many of them concern cost effectiveness research and rationing. It’s too much to answer them all, so let me try and make s few clarifications and further points.

    1) I’m sorry, but I don’t think I’m making a straw man argument here. If you really need me to prove that many, many, many people think that government involvement, or cost-effectiveness, or even comparative effectiveness research leads to RATIONING, then you haven’t been paying attentions. Death panels, anyone?

    2) In a similar vein, if you don’t think there are many people (including politicians) who think we do not ration right now, then you are not paying attention. Go ahead. Ask you representative if our health care system rations right now, and see what answer you get.

    3) We are not currently in a system of markets and prices rationing effectively. We are in a system where if you can pay for care, or for decent insurance, you get it.  Otherwise, it’s significantly more likely you can’t. Unless you’re over the age of 65, in which case, you’re almost positively getting it.

    4) Converting to a “voucher” system as Rep. Ryan proposes will not result in the market all of a sudden rationing effectively. If you believe that, then you should believe that the PPACA exchanges will result in the same outcome. I don’t believe the PPACA will do so. I doubt conservative opponents of the PPACA believe it will do so either. So why will Rep. Ryan’s plan?

    5) I don’t believe cost-effectiveness research is the be-all and end-all of medical decision making. I think it can be a powerful tool to help us make better decisions. I own all its limitations, but I don’t think the perfect should be the enemy of the good.

    6) I get that there is a philosophical difference between many of us. I believe that a well informed and public panel can make rational decisions at the extremes of costs and care. I get that this scares the crap out of some of you. That’s why I content is has to be public, reversible, and accountable.

    7) I’ve said this before and I will say it again:

    [I] think we can have a panel of experts (which should include physicians) try and determine which care isn’t worth the money and stop spending as much public money on that. This will mean that if individuals want to get that care anyway, they have to pay for it themselves.

    I’m not advocating for a system where rationing occurs in such a way that government or experts tell you how to spend your money. I’m advocating for a system where government/experts decide what government should spend its money on. People are free to spend their own money above that.

    • There was a recent study of drugs for macular degeneration. An older drug costs $50/dose. A newer drug costs $2,000/dose. The study found no differences between the two drugs.

      Who believes the government should pay for the $2,000 drug?

    • I live in Switzerland, where, if you want to pay for it, you can buy an insurance policy that covers all kinds of clearly ineffective treatments: homeopathy, hot-springs spas and “wellness hotels”, chiropractic treatments for cancer, you name it. I think its great that such options are available to those who are able and willing to pay for them. But it is all privately funded, no government subsidies given.

      There are recurring discussions about adding such treatments to the mandatory, take-all-comers basic insurance package. Thankfully, no real threat to do so. The decision process is, as Aaron suggests, dominated by medical experts, very public, and reversible.

    • It remains unclear to me why some people think private insurance, which cannot control costs, will suddenly be able to do so if we add in seniors. It seems much more likely that they will just keep doing what they have been doing.


    • Will you lay out what would satisfy you as “efficient rationing”? Not in vague “people should get good care at a good price” sophistry: I’m talking attainable numbers. When would you look at the health care market and conclude that it is efficient?

      Or, by means of example, can you describe a market that you do consider to be efficient? Automobiles? Legal Services? Bananas?

      First, define the good. Then, think about how to get there.

    • I] think we can have a panel of experts (which should include physicians)

      The trick would be to keep physicians, with their natural bias toward more care, from dominating a such a panel.

      • I think there are many physicians who are not biased in favor of more care, including me. There are bales of scientific articles, mostly by physicians, supporting lower intensity approaches. Some areas of the country — the Upper Midwest and the Pacific Northwest — have a relative bias in favor of less care and less high tech/high cost care, as do many institutions — Mayo and Kaiser are examples, but there are many more.

        Unfortunately, there are also many physicians with the opposite bias, and there are areas of the country — especially the Northeast and the Sunbelt — where the dominant health care culture has that bias. The major media tend to be concentrated in those areas, and the media and the public tend to also have a bias in favor of the dramatic and the high tech rather than the more mundane and less dramatic.

        The trick in creating a successful expert board is to choose people who have a bias toward scientific evidence and who are willing to insulate themselves from the financial forces that push toward higher costs and higher profits. That is not easy, but not impossible. We can, however, expect lots of pushback. The recent Don Berwick episode is one example.