Friday, December 3, 2010

“Death Panels” redux

One of the canards slung at the Affordable Care Act is that it creates “death panels” that would allow the government to deny patients life-saving treatments, even though two independent and non-partisan fact-checking organizations found it would do no such thing.

I don’t bring this up now to rehash the debate, but because the New York Times has a story today on Arizona’s decision to deny certain transplants to Medicaid enrollees - “death by budget cuts” in the words of reporter Marc Lacey. His story profiles several patients who died when they were unable to raise money on their own to fund a transplant. Lacey quotes a physician expert on transplants who flatly states, “There’s no doubt that people aren’t going to make it because of this decision.”

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.”

Lacey writes that the state based its decision on “analysis . . . of the transplants that were cut, which many health experts now say was seriously flawed. For instance, the state said that 13 of 14 patients under the state’s health system who received bone marrow transplants from nonrelatives over a two-year period died within six months. But outside specialists said the success rates were considerably higher, particularly for leukemia patients in their first remission.”

As a non-clinician myself, I don’t feel qualified to express an opinion on whether the evidence supports the efficacy of transplants for patients with these conditions. But if you take Arizona Medicaid officials at their word, Arizona is making decisions based on the expected quality and longevity of life that may result from a given intervention and the cost of that intervention. Isn’t this the kind of “rationing” that critics of “government-run” health care rail against, only in this case it is a conservative-run state governor and legislature that is implementing such restrictions to save the state’s taxpayers some money?

Transplants, because the demand will always exceed the supply, have always been rationed based on medical criteria, although Arizona is taking it to a different level by explicitly taking cost into account.

The problem with Arizona’s approach is that the impact will fall disproportionately hard on the state’s poor. They don’t have access to private health insurance coverage that includes transplants and they don’t have the resources to fund transplants on their own.

The larger point is that the United States already limits access to health care, as all countries must do - because it isn’t possible for everyone to get everything they want or need. There is a superb discussion of this point in the November 24 issue of JAMA. Drs. Meltzer and Detsky write:

“Rationing already takes place [in the United States] in many ways in health care. Managed care is exactly a form of rationing in which a private insurer determines whether patients should or should not receive services. In addition, private sector rationing injects profit motives into the calculations. . . It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.”

Tossing around words like “death panels” and “death by budget cuts” instills fear, when what we need is a reasoned discussion of how finite health care resources should be allocated equitably and rationally, and by whom - not just in Arizona, but throughout the United States.

Today’s questions: What is your reaction to Arizona’s decision to deny coverage for some transplants? Do you agree that all countries, including the U.S., ration care in some manner, and if so, is there a better way?


Steve Lucas said...

In the case of transplants there will always be a large population needing organs than organs available, thus rationing exist as a part of the issue.

Moving forward we have those who have made life style choices involving drugs or alcohol that will removed them from contention.

Now things become difficult as often the chronically ill are unable to find and hold the jobs that would be associated with the insurance coverage needed to fund a transplant.

Finally we have those who are fortunate enough to have the positions, income, insurance, and life style that will make them candidates for transplants. The system tends to favor these people in a self regulating environment.

We then face the negative issues of money driving the process. Some time ago we saw a Japanese criminal given a transplant after a large contribution to a west coast hospital. Here in the east we have seen a large transplant center rocked with scandal concerning the use of substandard organs, all the while defending the program as financially lucrative.

I saw this played out a few years ago in a different forum as only weeks after loosing my brother to liver failure I lost a friend to cancer. His end of life battle was with the oncologist who stated: you have insurance and assets; we need you in the hospital. This doctor was more than willing to spend his life savings in a futile effort to extend his life by weeks.

This doctor also made repeated calls to his wife promising “treatments.” He was well aware he was terminal and end stage and did not want to end his life in ICU connected to a ventilator that someone would have to disconnect.

I have been fortunate to spend time in Canada and travel to France yearly for the last 20 years. What I have taken away from that experience is a sense of practicality to health care. WW II forced decisions about many issues, health care being one. Live a healthy life style and you will live a long life, live an unhealthy life style and your life will be shorter. Your choice.

Along with the lower cost and better outcomes I have found there is not the fixation or anxiousness concerning health issues. This contrast with a 65 year old friend who is outraged he may not get a heart transplant, even though he has no health issues.

We need to remove some, but not all, of the emotional aspects of this issue. We need to look at quality of life issues, $100,000+ for a few weeks in ICU may not be the quality of life we want at the end of our life.

We need advocates’ who will stand up to the oncologist, surgeons, and hospitals that have a financial interest in the most expensive treatment and state: I know this person, and this is not how they wish to end their life.

Steve Lucas

Harrison said...

I think this was worse than rationing. The people effected had been promised funding. They had been given the go ahead to make appropriate plans. Therefore they really hadn't reached out for other potential sources of funding.

Then the funding source, the state of AZ in this case, backed out.

Rationing, even for budget reasons, would not create expectations of funding for life saving procedures and then back out in such a cruel manner.

Rationing would take political courage -- to tell people to not depend on the funding in the first place.

I don't know if the Arizona lawmakers acted with courage or not. Maybe.
But what they did was clearly cruel and unfair.

When you are not up front then you are being dishonest.
That is the same as stealing.
In this case you are stealing from people who are pushed into bad situations with limited choices.

It would take courage to tell them up front that they cannot count on funding.
Then the people effected would have the right to decide on whatever outcomes they must face.

That is not what happened.
The state of Arizona chose to be dishonest and unfair to a vulnerable group of people.


ryanjo said...

Once government is involved in regulating and funding an industry, medical decision-making based on economic rationing is inevitable. Another grandiose government program, now woefully underfunded, sound familiar? (Hint: PPACA).

Our government, of course, is responsible for the current dominance of managed care companies over clinical decision-makers, by creating the regulatory climate allowing the insurance industry to establish HMOs in the 1980s. Practicing physicians now feel the presence of the managed care plan (not to mention the plaintiffs attorney) in every patient encounter.

The present Arizona transplant controversy reminds me of the first media reports years ago, as HMO administrators tossed women out of the hospital hours after childbirth. After initial public outrage, the fuss died down, and now many patients blame the doctor if their insurer or Medicare/Medicaid disapproves a test or charge. The liberal media will move on, as before -- the politicians and the insurance execs know this.

Which is why so many of us continue to question why our organization, the ACP, continues to actively support the ACA, a law that extends influence of our government's questionable ethics to many more Americans, and at a huge future cost. It was heartening to see the ACP sponsoring recent video interviews of ACP doctors, reflecting how the SGR negatively impacted themselves and their patients. I suggest to our ACP leadership that the seeds of a future video are seen in Arizona now.

Actually, I think "death by budget cuts" describes it pretty well.

PCP said...

The only person capable of doing the task that Steve Lucas speaks of, is a strong Primary care Physician who has taken care of the patient and his or her family through think and thin for more than a decade.
Sadly that person is a dying breed. Could this partly be behind out of control health care costs?
Would decisions/explanations from such a trusted individual be perceived by patients as something other than health care rationing? Surely that person does not have a profit motive. What then if that person loses their very professional autonomy?
Important questions indeed.

Steve Lucas said...


You have focused on the true issue we are discussing, and the very doctors we are looking to control cost are being, as you point out, pushed out of the system.

Sadly, we the patients are poorer for it.

Steve Lucas