Friday, November 20, 2009

When will we face the real issues?

An obsession with technology coupled with consumerism has led to the excesses so evident in today’s practice of medicine. An excellent example was recently published by F. Knauf and P.S. Aronson, ESRD As a Window into America’s Cost Crisis in Health Care, Journal American Society of Nephrology 2009; 20:2093-7, which describes how nephrology (kidney) treatments are now being applied far in excess of the original indications.

Kidney dialysis and transplantation first became available in the early 1960s. Because of cost, most people were excluded from these life saving benefits. To meet this public need, the Bureau of the Budget created a committee headed by the highly regarded nephrologist, Carl Gottschalk. This committee submitted their report in 1967 calling for federal funding to make dialysis and transplantation available through Medicare to all Americans. In 1972 this concept was approved by Congress.

The Gottschalk committee proposed that dialysis would be limited to otherwise healthy people mostly under the age of 54 years. Thus it was anticipated that dialysis or transplantation would be appropriate in 1 of 5 patients with ESRD (end stage renal disease). Maintaining these criteria would add about 40 patients/million population to the dialysis and transplantation cohort yearly. But now that number is about 400/million, with patients over the age of 75 the fastest growing sub-group, most with serious co-existing diseases causing an increase in patient suffering, hospitalization rates, and a dramatic increase in costs.

Is this good medicine? Does this liberalization of criteria lead to better medical care? Data clearly demonstrate that older patients who are non-ambulatory or with other co-morbidities frequently die in the hospital rather than in the community while receiving little or no benefit. Another recent paper in the New England Journal of Medicine, 2009:361; 1539-1547, demonstrated that nursing home patients, after one year on dialysis, have a death rate of 58 percent and a significant decrease in an already limited functional status. Instead of the careful and thoughtful use of technology mixed with insight and compassion, we in America seek an inappropriate technological solution no matter how great the evidence that it will not be beneficial. Thus, the only pathway to successful health care reform is to develop mechanisms to alter the present medical culture. The approach should be based on the individual characteristics and needs of each patient.

Unfortunately the present plans for health care reform do not in any way address these basic problems. As stated in a recent (Nov. 16, 2009) op-ed essay in the Washington Post by Robert J. Samuelson,
There is an air of absurdity to what is mistakenly called "health-care reform." Everyone knows that the United States faces massive governmental budget deficits as far as calculators can project, driven heavily by an aging population and uncontrolled health costs. As we recover slowly from a devastating recession, it's widely agreed that, though deficits should not be cut abruptly (lest the economy resume its slump), a prudent society would embark on long-term policies to control health costs, reduce government spending and curb massive future deficits. The administration estimates these at $9 trillion from 2010 to 2019. The president and all his top economic advisers proclaim the same cautionary message. So what do they do? Just the opposite. Their far-reaching overhaul of the health-care system -- which Congress is halfway toward enacting -- would almost certainly make matters worse. It would create new, open-ended medical entitlements that threaten higher deficits and would do little to suppress surging health costs. The disconnect between what President Obama says and what he's doing is so glaring that most people could not abide it. The president, his advisers and allies have no trouble. But reconciling blatantly contradictory objectives requires them to engage in willful self-deception, public dishonesty, or both.

There is no doubt that this country needs health care reform that addresses our aberrant medical culture. There certainly is no sign of that at this time.

3 comments:

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