President Obama’s Real Waterloo – a Pacemaker

 

After a tumultuous August marked by repeated attempts by President Obama to calm Americans’ fears and sell them on his version of health care reform, we are now faced with the prospect of more of the same as we head into Wednesday’s Presidential Address to the joint session of Congress.  As we endure this endless process of “Mad Men” meets the Presidency, along with  President Obama’s dwindling audience, we are no nearer to accepting Mr. Obama’s words regarding his health care program.  With Mr. Obama in full campaign mode, the “facts” he tells us about his health care program are not some reliable bedrock to build a health care system on, but rather the “facts” underlying a political campaign promise – understood by all to be spun and twisted into the most desirable shape for the purpose of persuading.  In this continuing process of campaigning, rather than governing, President Obama is losing not only approval ratings, and political capital, but also his very credibility.

Before we hear Mr. Obama’s revised “vision” of “health insurance reform” that has been tweaked and focus-tested for our current consumption, let’s return to his original and least practiced attempt to describe this vision – the attempt that has, perhaps sounded the most discordant note in the whole debate, and which may have permanently damaged his efforts to move health care reform forward. This occurred during the June 24 town hall meeting at the White House, when he was asked by Ms. Jane Sturm whether “any consideration” would have been allowed for her 100 year old mother’s “spirit” as she sought a pacemaker to address her arrhythmia problems ( a pacemaker which, under the present Medicare system, had indeed been implanted, giving the woman five more years of life to date).  There are several disquieting passages in Mr. Obama’s response that invite our scrutiny and analysis.

1. “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 –”

Clearly Mr. Obama thinks “we have to have rules” to determine when patients will receive an intervention such as a pacemaker.  It seems that the professional “judgments” made by the woman’s physicians, were “pretty subjective” and not a sufficient basis “…to provide good, quality care for all people.”  It would seem that the “rules” Mr. Obama wants would lay out how “all people” with this condition/diagnosis will be treated.  Such “rules” are clearly not included in the bills we are considering. These could 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. I don’t want bureaucracies making those decisions.”

“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, sensitive decision” he is talking about – a decision, in effect, to end care which, in turn, results in the “end-of-life.”  Immediately he senses he is in trouble and says that “I don’t want bureaucracies making those decisions.”  However, later on in the conversation he seems to rely on the bureaucracy to “let doctors know” what the decision should be, if not for the decision itself.

3. “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.”

This statement is central to how the system will work and seems to indicate 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 elderly patients access to various treatment modalities.   The House bill, indeed, establishes a “Center for Comparative Effectiveness Research.”  To implement the comparative effectiveness 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 mechanism to  “let 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. If they’re not being made under Medicare and Medicaid, they’re being made by private insurers…”

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/regulations and are likely to reach the same treatment decision.   In brief, under Mr. Obama’s system 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, (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.  In response to Ms. Sturm’s statement that her mother’s repeated hospitalizations prior to receiving the pacemaker may have cost Medicare more money than the pacemaker procedure itself Mr. Obama stated:

“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.”

Clearly Mr. Obama envisions that “experts” will be “looking at this” diagnosis and demographic, and “advising doctors”  what treatments “may ultimately save money.”   This “advising” is done at the behest of “we,” (the Government).  However, what the “experts” are “looking at” isn’t this specific case of Ms. Sturm’s mother, but rather they are “advising … 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 will be developed by the “experts” for “all people” in this demographic and with this condition/diagnosis.  This unbelievable exchange shows that under Mr. Obama’s system, treatment guidelines will be devised “across the board”  by the “experts” based on statistical “evidence” which is not related to any specific patient’s situation or their doctor’s “judgment” or preference. The decisions that Mr. Obama says are currently ” being made in one way or another” are, in fact, based on the traditional doctor-patient relationship.   Mr. Obama has seemingly replaced that with the bureaucratic expert-doctor relationship.  The patient apparently has no voice or advocate.

Perhaps the most 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, 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, more worthy, citizens).

So, back to the health care 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 “judgments.”     
  • It employs comparative effectiveness cost analyses performed in advance by “experts” to inform physicians’ “sensitive decisions” which are recognized to result in “end-of-life.”   (is anyone surprised that some see “Death Panels?”)
  • It is comprehensive – applying to all cases “across the board” that are 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” (perhaps the Center for Comparative Effectiveness Research, among others).  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.  

This is what we heard on the evening of June 24, 2009, and Mr. Obama has said nothing equally frank and unscripted since that time that would lead us to think this is not, indeed, his “vision” of health care as we move forward.  True, not everyone has played it back with this degree of relentless scrutiny, but nevertheless, this exchange lingers as a vaguely disquieting memory in the public consciousness, coloring our perception of the proposed health care reforms. Mr. Obama will need to do more than just deliver a good technical speech about “Health Insurance Reform” on Wednesday night.  The President needs to dispel the public’s justifiable misgivings about his “vision” of health care itself.   A good start would be to totally repudiate the robotic, almost amoral response he gave to Ms. Sturm during the June 24 Town Hall meeting.   I doubt that he can do so, because I believe that, unfortunately, this unrehearsed response goes to the very heart of Mr. Obama’s nightmarish “vision” for us all. 

The Skeptic

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