Thursday, September 24, 2009

"You can't always get what you want . . .

. . .But if you try sometimes, well you might find,
You get what you need."

So sings Mick Jagger in this rousing refrain from the hit song on the Rolling Stone's 1969 "Let it Bleed" album.

Most people wouldn't look to Mick Jagger and Keith Richards as a source of child-raising advice. But I have quoted this phrase many, many times to my kids. Like when my 17 year old daughter recently insisted that she needed a "cool" new cell phone, when she already had a perfectly good phone. Of course, telling her that "you can't always get what you want" didn't help my approval rating that night.

The advocates of health care reform are dealing with something similar. What people want is unlimited health care, paid for by someone else, at no cost to them. What they need is access to care that is reasonably affordable, with some limits to ensure that the total price tag doesn't bankrupt the country.

It is the "limits" part that has people upset. They instinctively understand that health care reform will involve some limits on their own care, even as heath reform advocates try to sugar-coat things by saying it can all be paid for by reducing waste and fraud and promoting "value" and "efficiency" in health care. We can deny all we want that health care reform will lead to rationing, yet much of the public believes that in the end, the government will put limits on the care they want.

I think this explains the ambivalence about health reform in recent polls. The Kaiser Family Foundation's August tracking poll found that 45% of voters felt that health care reform would make "the country as a whole" better off but only 36% felt it would do the same about them and their families. Only 29% thought it would make the quality of care better for them personally, but 37% thought it would make quality "in America" better. 42% thought that it would make wait times for non-emergency treatments personally worse for them. 51% were more worried that Congress would pass a bill that won't be good for them and their family, compared to the 39% that were more worried that Congress wouldn't pass a health care reform bill this year.

The public's concern about the impact of health care reform on them personally is appropriate and understandable. President Obama has tried to blunt this by emphasizing how people with health insurance will benefit from reform, and some other recent polls suggest that he is making progress.

I think the President has not squared with the American people that it isn't possible for everyone to get everything they want. But the critics of his efforts have also done a disservice by screaming "rationing" every time the discussion turns to controlling costs.

The issue, in my mind, is not whether there will be limits - call it rationing if you must, although it is such a loaded term. Instead, the question is who will do the rationing and how. Should we continue to leave it to insurance companies to limit services by denying coverage for people with pre-existing conditions, cancelling coverage when they get ill, and finding every possible reason to deny claims for services?

Should we do it based on who has access to health insurance and who doesn't? By how rich your benefits package is? By whether you work for an employer who can provide coverage, or whether you work for a small company that cannot? By giving everyone a high deductible plan so they are more responsible for the cost of their own care? By making smokers and others who have so-called "lifestyle" illnesses pay more? By having the government fund research on the clinical effectiveness of different treatments and then designing benefits, coverage, and payment policies around such research?

Good arguments can be made for, and against, almost all of these approaches, but at least they recognize the simple fact that when it comes to health care, you can't always get what you want, but if you try sometimes, well you might find, you get what you need.

Today's question: Do you think it is possible to engage the public in a rational discussion about rationing?


Jay Larson MD said...

"A person is smart. People are dumb, panicky, dangerous animals, and you know it." Agent K. Men in Black.

Because of different ideologies, a group of people is difficult to communicate with. Conversations vary based on the belief systems that each conversant has.

Several patients have discussed health care with me during office appointments. After discussion, they have a much better grasp of the situation. I also have a better understanding from the patient's point of view.

We do not discuss rationing specifically but discuss treatment options that may be less expensive than others.

Unfortunately, we can not have one on one conversations with 300 million people, because that is what is needed to have rational conversations.

Rich Neubauer MD said...

I don’t think it is a question of WHETHER a rational discussion with the public about rationing is possible. Rather, I think it is an absolute necessity that such a discussion has to occur. Questions and issues that are relevant to how that discussion could/should unfold include 1) when it may be possible/best to have that discussion 2) the terminology that might be used to soften the visceral response that it will engender 3) realization that we ration care every day right now, so it is not so much a question of newly rationing, but rather doing so more intelligently and more fairly and 4) including in the discussion concepts of public health, preventive care, and an outline of basic services that everyone should have access to.

The ACP Health and Public Policy Committee (HPPC) is planning to take up this important topic at its meeting next month and eventually generate a paper on the subject. Eventually the paper will appear in the policy compendium on the ACP Web site, which is a great place for members to explore the details of ACP policies.

In terms of when the public discussion needs to occur, I think for a variety of reasons, that will be best accomplished after we’ve taken steps to expand coverage to all our citizens. It will only be then that we can rationally discuss how to control overall costs, and how to spend reasonable but ultimately finite dollars on health care.

We will need to find ways of making the discussion palatable to the public and remove the discussion from the realm of partisan politics. The conceptual framework will need to include comparative effectiveness research, public health considerations, and be ethically grounded. The process will likely need to be transparent. It will need to be tied in with biomedical research so we continue to be leaders in medical science. Special interest groups need to be able to have a say, but cannot be allowed to thwart the discussion.

The fact that we ration care right now has been amply pointed out in the current debate, but the discussion seems to have resulted in special interest groups grinding their heels in defending their current situation. This is in part why I feel that the discussion would best happen after coverage is extended to all or most of our citizenry.

Finally, along with the rationing discussion, we need to re-order priorities. We need to build up the primary care system on a nation-wide basis so that everybody has a medical home.

Physicians are in a unique position to contribute and help to nudge the public toward having this discussion. Organizations like ACP need to courageously take a leading role.

Craig A. Piquette said...

I agree with Dr. Neubauer that the conversation on rationing can not occur until everyone is in the tent. The conservatives have twisted the debate on palliative care so an honest and open conversation can not occur at this time. I am not convinced that the conservatives feel a need to increase the coverage for all who need it. Their focus appears to be on controlling the costs of health care but costs will go up if you cover the currently uninsured and underinsured. The current debate is avoiding the discussion of rationing in order to focus on covering everybody and in the current political environment I believe that is the right strategy.

Steve Lucas said...

Rationing is such a hard topic for many to deal with in an adult manner. I was discussing the high cost of end of life care with my dentist and hygienist. My example was the cancer patient in the ICU, on a ventilator, who then receives a six figure treatment that will only extend life a few weeks. I did not see the rational for this treatment.

They basically thought I was a monster, devoid of all compassion. My compassion is for the patient who is being forced to suffer through this process at the request of someone else.

We have such a tradition of expending ever larger amounts of money in the pursuit of extending life The new reality of ever more expensive drugs and treatment options have not kept up.

Doctors do need to take the lead in explaining that because something is available, it may not be in the best interest of the patient, and yes, that does mean making some hard decisions.

Steve Lucas

PCP said...

"Unfortunately, we can not have one on one conversations with 300 million people, because that is what is needed to have rational conversations."

Jay, you are absolutely correct. Which is why these conversations should be happening between Doctor and Patient in the exam room and with the least 3rd party interference possible. That is where health care policy should lead.
The further we stray from this as a country the more irreconcilable our differences will become.
Does anyone believe that any of the health care policies of the last 2 decades have served to strengthen the Doctor-patient relationship? Furthermore, I believe much has been done IMHO both intentionally and otherwise to weaken/undermine it. I see DTC advertising, the rise of the Pharma marketing machine, the expansion of scope of practice for allied health professionals, policies to favor the Insurance industry, the formation of local Hospital monopolies, and many more such items are quite frankly geared toward weakening the Doctor-patient relationship. So lets not whine about the consequences.

The truth of the matter is that, to ration resources properly, the needed foundation pillars are critical. A shared sense of responsibility, pricing transparency, and finally trust in a Personal physician. The current Generalist Physician reimbursement model and 10 minute visits are quite simply not conducive to the growth and development of this vital aspect of our health care infrastructure.
The role of the Generalist Physician as opposed to "a primary care provider" must be more clearly defined. It must be strengthened such that the patient trusts this person to be central in their care once more.
Current and recent policy is farcical at best in addressing the hard choices needed to make this the way our system works. Contrary to what the ACP believes the current legislation modeled after the Mass. model does nothing to get us there.

Unknown said...

The underpinings of the disagreements in the health care reform process is a struggle between an attempt to maintain the financial status quo versus a desire to improve the distribution and access to health care. Any other consideration is a distraction to a useful resolution.

No one with a working knowledge of providing health care would seriously think that "rationing" and "death panels" would be part of a government sponsored universal health plan. Two current major government health systems, Medicare and the Veterans Administration surely do not ration care nor use death panels.

The ACP could provide much clarity to the health care reform discussion by describing the big picture as it stands now: how much money in premiums do insurers collect, how much do they pay out for services, what percentage of the payout the various segments of the health care industry collect, where does the disability system fit into the mix? If the ACP has published such an analysis, please direct me to it. Thanks.

Anonymous said...

I am not sure that rationing care is politically acceptable to any broad audience. It's ethos would seem incomprehensible to most.
The antidote could be stronger physician-patient rapport as exemplified in Dr. Larson's posting.
This could be achievable with greater emphasis on primary care, which would be a consequence of broader and more affordable coverage.

Betty said...

Nice post. I have to say I agree with the comment above which states that the antidote could be stronger doctor-patient rapport. There is a great book called "Time to Care" by Norman Makous, M.D. who proposes bringing the doctor-patient relationship back to the center of the health care system.