The purpose of this blog is to explore the Health Care Reform Crisis, (more serious than the Health Care Crisis) including both the House and Senate bills, to determine what they intend. But before we get involved in the details of these documents, lets start by looking at what we think President Obama himself intends the new system to do.
The following discussion is excerpted from a transcript of the June 24, 2009 Town Hall meeting at the White House. Interestingly, the Democratically-controlled Congressional Franking Commission refused to allow Rep. Ken Calvert (R-Calif.) to quote a portion of the following discussion in a newsletter to his constituents- denying him the “franking” (free mailing) priveleges that all Congressional members enjoy. In effect, political censorship … of an already publicly-aired discussion! This indicates how damaging this quote is, and how much supporters of the Congressional plan would like to bury it:
“Q And we have with us a couple of people who really represent the opposite ends on this spectrum too. I want to talk, if I can, to Jane Sturm. Your mother, Hazel Homer —
“Q She’s 105 now, over 105. But at 100, the doctor had said to her, I can’t do anything more unless you have a pacemaker. I said go for it, she said go for it. But the arrhythmia specialist said, no, it’s too old. Her doctor said, I’m going to make an appointment, because a picture is worth a thousand words. And when the other arrhythmia specialist knew her, saw her joy of life and so on, he said, I’m going forward. So that was over five years ago. My question to you is, outside the medical criteria for prolonging life for somebody who is elderly, is there any consideration that can be given for a certain spirit, a certain joy of living, quality of life? Or is it just a medical cutoff at a certain age?
“THE PRESIDENT: I don’t think that we can make judgments based on people’s spirit. That would be a pretty subjective decision to be making. I think we have to have rules that say that we are going to provide good, quality care for all people —
“Q But the money might never have been there for her pacemaker or for your grandmother’s hip replacement.
“THE PRESIDENT: Well, and that’s absolutely true. And end-of-life care is one of the most difficult, sensitive decisions we’re going to have to make. I don’t want bureaucracies making those decisions. But understand that those decisions are already being made in one way or another. If they’re not being made under Medicare and Medicaid, they’re being made by private insurers… And all we’re suggesting — and we’re not going to solve every difficult problem in terms of end-of-life care; a lot of that is going to have to be we as a culture and as a society starting to make better decisions within our own families and for ourselves. But what we can do is make sure that at least some of the waste that exists in the system that’s not making anybody’s mom better, that is loading up on additional tests or additional drugs that the evidence shows is not necessarily going to improve care, that at least we can let doctors know, and your mom know, that you know what, maybe this isn’t going to help, maybe you’re better off not having the surgery, but taking the painkiller.
“Q What I wanted to say was that the arrhythmia specialist who put the pacemaker in said that it cost Medicare $30,000 at the time. She had been in the hospital two or three times a month before that, so let’s say 20-30 times being in the hospital, maybe going to rehab — the cost was so much more, and that’s what would have happened had she not had the pacemaker.
“THE PRESIDENT: Well, and that’s a good example of where if we’ve got experts who are looking at this and they are advising doctors across the board that the pacemaker may ultimately save money, then we potentially could have done that faster. I mean, this can cut both ways.”
Considering how scripted and managed the President’s Town Hall meetings have been, this is a remarkable exchange in many ways. It seems to foretell many of the elements of the plan and, (unlike the proposed bills) provides a clue as to how the system might work.
1. “I think we need to have rules …” Professional ” judgment,” such as that used by the woman’s physicians, is “pretty subjective” and not a sufficient basis “…to provide good, quality care for all people.” We need “rules” that determine how all patients with this condition/diagnosis will be treated. Such “rules” are clearly not included in the bills we are considering. These will come later in implementing regulations or in some of the broad authorities granted to the bureaucracies, perhaps through issuing guidance. This is one of the truly disconcerting aspects of the proposed bills, because we don’t actually know the shape of the final plan, yet we are being asked to give the Government bureaucracy broad authority to flesh out that plan later as they see fit.
2. “End-of-life care is one of the most difficult, sensitive decisions we’re going to have to make.” “End-of-life” is a term generally reserved for the last months of life. But since Ms. Sturm has already informed the President that her mother has lived for 5 years subsequent to the pacemaker implant, Mr. Obama is obviously using the term in a different manner. Mr. Obama appears to mean that denying Ms. Sturm’s mother a pacemaker would, most likely, have ended her life, and that this is the “difficult decision” he is talking about – a decision, in effect, to end care which, in turn, results in the end-of-life. Immediately he senses the trouble he is in and says that “I don’t want bureaucracies making those decisions.” However, later on in the conversation he seems to rely on the bureaucracy for at least “letting doctors know” what the decision should be, if not for the decision itself.
3. If there are “…additional tests or additional drugs that the evidence shows is not necessarily going to improve care, then at least we can let doctors know, and your mom know, that you know what, maybe this isn’t going to help, maybe you’re better off not having the surgery, but taking the painkiller.” This statement is central to how the system will work and reveals the intention to use “evidence”-based medicine to identify appropriate treatment options, and to use comparative effectiveness analysis to determine which treatment option – in this case, therapeutic pacemaker vs. palliative drug – is more cost-effective. These concepts – evidence-based medicine and comparative effectiveness- have notoriously been used by the National Institute for Health and Clinical Excellence (NICE) of the British National Health Service to deny access to care to the elderly. The House bill, indeed, establishes a “Center for Comparative Effectiveness Research.” To implement this template, we seem to have a set of known and agreed upon “rules” so that “we can let doctors know and your mom know” the most cost-effective treatment regime for her demographic group. The “we,” who, is charged with letting folks know, seems to be the Government, so published regulations or guidelines would seem to be the likely method of “letting doctors know.” Clearly, the bureaucracy is back in the decision-making loop after their previous banishment by the President.
4. ” But understand that those decisions are already being made in one way or another.” Yes, and this is, perhaps, the crucial point of this exchange – Ms. Sturm was able, under the present “broken” system, to find a doctor who made a decision to give her mom the pacemaker, and Medicare supported that decision. In Mr. Obama’s system, when “the evidence shows” a certain treatment ” is not necessarily going to improve care ” then “we can let doctors know” … how to treat this type of patient. So, basically all doctors will have the same evidence and treatment guidelines and, theoretically, the decision will be made the same way by all, especially if they wish to be reimbursed. The decisions that under our current system “are being made in one way or another” are, in fact, based on the traditional doctor-patient relationship. Under Mr. Obama’s system, it appears these decisions will be made “across the board” (see next quote string) by the “experts” based on statistical “evidence” which is not related to any specific patient’s situation or their doctor’s judgement or preference. In brief, Ms. Sturm will probably not be able to find a doctor who will decide to give her mother a pacemaker – period. Mr. Obama’s often repeated disclaimer that these “decisions are already being made” completely, totally (and, perhaps, intentionally) misses the point, because the decisions that are currently being made under our “broken” system appear much more flexible, appealable, personalized, and humane than those that will be made under Mr. Obama’s system!
5. “If we’ve got experts who are looking at this and they are advising doctors across the board that the pacemaker may ultimately save money, then we potentially could have done that faster.” So there will be “experts” that are “looking at this” diagnosis and demographic, and “advising doctors” regarding appropriate treatment at the behest of “we,” i. e. the Government . However, what they are “looking at” isn’t this specific case of Ms. Sturm’s mother, but rather they are ruling “across the board” referring to all such cases. So, in Mr. Obama’s mind, this new information revealed by Ms. Sturm is just more “evidence” that would be statistically factored into the rule or guideline that has been developed by the “experts” for persons of this demographic and with this condition/diagnosis. So once again, after a brief disconcerting jolt of new data, the system is complete and perfect bureaucratic order has been restored.
Of course, the real chilling aspect of this last exchange is how easily Mr. Obama flip-flops on providing the pacemaker once he discovers that the Government might actually save money by providing it. His new position is that maybe we “could have done that faster,” … as opposed to not at all (lol), as he previously indicated. The medical appropriateness of the two treatment options were not changed by Ms. Sturm’s additional information. Only their relative cost-effectiveness changed, and therefore Mr. Obama’s bureaucratic judgment of what is appropriate treatment, has also changed. The patient’s health and quality of life are never even mentioned by Mr. Obama! This purely cost-driven sensibility reflects our worst fear regarding Government-guided health care, and illustrates the inherent clash of interests between the individual citizen-patient (who desires quality health care) and the Government-guider/provider (whose primary goal is to conserve resources for the bureaucracy, and for other citizens). If this system is implemented, this conflict will forever change the citizens’ relationship with their Government, making them bow low to those who should be serving the broad common interests of the people, not dictating the intimate details of their individual lives and deaths.
So, back to the “System” that Mr. Obama envisions. What did we learn about it from this exchange?
- It relies on the principles of “evidence”-based medicine rather than on physicians’ professional “judgment.”
- It employs comparative effectiveness cost analyses performed by bureaucrats to inform physicians’ “sensitive decisions” which are recognized to result in “end-of-life.” (can anyone say “Death Panel?”)
- It is comprehensive – applying to all cases “across the board” linked by common factors of demography and diagnosis – there are no exemptions for individuals.
- The traditional doctor-patient relationship will be superseded by “expert” opinion and guidance for key treatment decisions
- It employs published “rules” that are most likely regulations or guidelines for care, linked to payment.
- These “rules” will be developed by “experts” (the Center for Comparative Effectiveness Research?). These “rules” are not yet known to us because they are not described in the bills. Once the bills are enacted, Government bureaucracies will have a relatively free hand to develop whatever rules they wish.
- It is cost-driven, and appears to not give any consideration to ‘quality of life’ factors.
In fact, it appears to be one stone-cold, bureaucratic, mutha of a system.
This is our kick-off point.