Tuesday, July 15, 2008

The Healthcare Crisis: Can We Avoid Rationing?

As healthcare costs continue to spiral out of control, the buzz is already starting about having to ration healthcare in the future. It would boil down to providing care to those who would most benefit from it. But shouldn't it be the other way around? That is – providing only beneficial care to every patient and not pulling every expensive technological and procedural rabbit out of the hat in cases where the outcome is basically hopeless.

So what's the answer? Appropriate Care Committees. Can Appropriate Care Committees avoid the specter of healthcare rationing? My answer is a resounding yes! Let's take a look at a few of the things behind the explosion in healthcare costs.

Medicare alone is now spending over $400 billion a year, with expenses growing at an alarming rate. Congress and the President are dismayed, but haven't come up with a plan to prevent the impending financial disaster. One expert after another has said that inappropriate care is the biggest culprit in out-of-control costs - estimated at about $600 billion per year. Medicare is a large source of this problem.

So, how did all this come about. The causes are many and complex. Here are just a few.

• More and more use of expensive technology without evidence of superiority over existing methods takes advantage of lucrative quirks in the Medicare payment schedule. Some examples are proton accelerators for prostate cancer or the use of cardiac stents in patients whose conditions are just as easily managed with medication.
• Device and drug company advertising directly to the public helps promote an increasing sense of consumerism. Patients and their families have a virtual smorgasbord of drugs, devices, and procedures – all attractively packaged in the ads - that they can demand whether they'd be of any benefit or not. And, unfortunately, many physicians are loathe to say no to them.
• Medicare’s chronic under-funding of primary care and over-funding of specialists and subspecialists who perform many unnecessary procedures plays the largest role. The under-funding of primary care has nearly destroyed the old fashioned doctor-patient relationship, so there is a marked decrease in preventative care and poor management of the chronically ill.
• Medicare, in its attempt to save money, under-funds regular hospital bed care causing hospitals to emphasize expensive intensive care units and procedures which results in spending even more dollars.
• Medical societies have been reluctant or unable to enter national dialogues about important medical issues (like the Terry Schiavo case) or help set up a support system for practitioners who wish to practice high quality appropriate medicine but are afraid of lawsuits.

So here we are. Our healthcare system consumes over 17% of the gross domestic product, we spend more per person on healthcare than any other country in the world, but with worse health outcomes, and still have more than 47 million people uninsured.

What will the government do if these runaway costs are not controlled and bring our national economy to the breaking point? Enter talk of rationing. Make no mistake. It's a very real possibility.

How can we avoid rationing and maintain the ability to individualize every case? Appropriate Care Committees - system of committees on the national, state and local levels, created by Congress with the power of law behind them. These independently funded committees of physicians, nurses, and clergy would function to review various cases in hospitals and nursing homes to insure appropriate care and would have the power to withhold funding for inappropriate care. It wouldn't take long for the word to get out that inappropriate care is no longer a cash cow and the tangled billion-dollar web of who-does-what-and-why would quickly unravel and healthcare costs would plummet.

This system would also give the patient the benefit of an impartial opinion regarding appropriateness without any conflicts of interest since they would have no monetary or loyalty connections to a hospital, nursing home or physician. For the same reasons, they would provide support to physicians who want to provide appropriate care, but the patient or the families are demanding something else.

The cost saving of this system, along with changes in administrative structure (see post about the healthcare bank) could well head off the looming financial crisis that could lead to healthcare rationing.