Sunday, December 13, 2009

Medical Rationing: The Last Best Hope?

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In 1972, George Carlin, the irreverent comedian who believed that boundaries are meant to be crossed, listed the 7 dirty words that could never be aired. These were considered to be a broadcaster’s ‘never event’. While society’s prohibition against offensive language and images have relaxed exponentially, there are still words and expressions that are radioactive.

I am quite certain that health care reformers have conducted focus groups to determine which verbiage offends and which phrase soothes the skeptical public. Words matter. I used to think that studying linguistics was merely an academic pursuit for grad students. Not so. These wordsmiths can now find honest work on Capital Hill. They can educate politicians on the nuances of language and expression so that our elected officials can speak out of a third side of their mouths.

We all remember from the prior presidential campaign how a wayward sentence can be exploited by adversaries who are poised to pounce. Recall this remark that Barack Obama made on the campaign trail in San Francisco in 2008.

So it’s not surprising then that they [midwestern communities]get bitter, they cling to guns or religion or antipathy to people who aren’t like them or anti-immigrant sentiment or anti-trade sentiment as a way to explain their frustrations.

If only there had been a linguist on the speechwriting staff. Obama and his handlers wish there had been a 7 second delay so that his misunderstood remark could have been bleeped, like a Carlin epithet. I don’t fault the president for his oratorical misstep. Considering the unrelenting campaign schedule, it’s expected and forgivable that candidates are not on their game 24/7.

Health care reform (HCR) advocates know that words and phrases may matter more than substance. Seasoned D.C. pols make only occasional rhetorical gaffes. Freshmen congressmen, however, rely on linguistically-correct HCR cue cards so that their words will be on message. Obviously, there are pro and con versions for each side of the aisle.

HCR Opponents Say…............... HCR Supporters Say

Tax and Spend.....................................Invest in the Future

‘Death Panel’........................................Comfort Care

Government Run Health Care..............Public Option

Free Market..........................................Price Gouging

‘Jackpot Justice’...................................Patients’ Rights

Medical Rationing ................................Evidence-Based Medicine

Clearly, I am no politician because I support medical rationing, and I’m not afraid to use the smokin' hot term. Indeed, we ration resources in our own home. Our income is finite. Our family cannot run a deficit year after year, leaving our kids or their kids to pay the bill. We have our priorities and fund those activities that we feel are critical. Like most families, we run out of money before we run out of worthy pursuits. Since our kids and us can’t have it all, this means that we are rationers. I hope that no outraged reader will report us to child protective services for negligent parenting.

Sure, the stakes in health care are higher, but the principle remains. Resources are finite and medical care is infinite. Consider this shocking development recently reported in The New York Times. A new drug, Folotyn, was approved by the Food and Drug Administration (FDA) this past September against lymphoma, a blood cancer. The tab? A mere $30,000 per month. This makes other chemotherapeutics that cost only 10 grand per month seem like bargain medicines. What does Folotyn deliver for a monthly cost that exceeds many Americans’ yearly earnings? Not much. It shrinks tumors in a minority of patients, a common claim of benefit by cancer drug advocates. However, just shrinking a tumor doesn’t make a person feel better or live longer. Indeed, no mortality advantage of Folotyn users was demonstrated.

Can we afford to spend fortunes of money on treatments, even if approved by the FDA, that have no meaningful proven value to patients? Let me respond boldly to my own inquiry. We can’t and we shouldn’t.

Other medbloggers have voiced concerns about the struggle to achieve cost control.

Medrants, an academic physician, writes that...we cannot control costs if we indiscriminately order every possible test, every new expensive drug, and provide futile care.

Dr. Val points out that other countries are more aggressive about prioritizing health benefits than we are. She writes that in Canada, expensive chemotherapies are not commonly covered by the national health plan, and in Britain, age is a determinant for transplant eligibility.

Medinnovations, a thoughtful blog by Richard Reece, M.D. states the obvious that the supply of health care is a limited resource, and the demand in an aging population is unlimited.

If the nation isn’t ready to ration hard, let’s at least ration easy and push back against expensive medical care of questionable or no value. This is the low hanging fruit. Harder choices will follow, and we will have to face them. Rationing can’t remain on the ‘dirty word’ list any more. We need to scream it out because it needs to be heard. Like Carlin, we need to break through some boundaries.


  1. It's not just healthcare reform supporters that tailor their words carefully, of course: opponents, including the health insurance industry, are equally (or even more) adroit at coining phrases and images in opposition to healthcare reform and continuation of the status quo. Indeed, opponents have created false-front organizations and faked correspondence from individuals (astroturf campaigns)---and gotten caught at it.

    The current version of healthcare reform does indeed save money in the long run.

    BTW, I strongly favor the public option, which is termed "government-run healthcare" above, over the insurance-company-run healthcare we now have. I have no problems at all with the administration of my Social Security payments, and I would bet the government would be equally efficient acting as an insurance company, covering the cost of care and charging premiums uninflated by the need to continually increase profits.

  2. Come to think of it, the government's already doing that with Medicare, which people in fact like---so much so that even the GOP won't badmouth the program.

  3. Anyone with a knowledge of basic economics knows that rationing of medical care is inevitable because the demand is growing as baby boomers age and the supply is not. Increased demand without increased supply means higher costs or rationing or a combination. When neither the patient nor a third party payer can or will pay the extra costs, a service is not performed. When price is artificially lowered, shortages occur. No amount of wishful thinking will enable Congress or anyone else to repeal the laws of supply and demand. Although rationing is inevitable, the question is who makes the decision to deny a service, and I don't think there is a satisfactory answer to the question. In a totally free market, the person with no money is denied the service. In a market dominated by insurance companies, they deny the service. With all the fire that the insurance companies have taken for denying needed services, I don't see that government bureaucrats will be any more compassionate or rational than insurance company bureaucrats. Replacing insurance companies with government agencies exchanges one kind of bureaucrat for another.

    I have been a bureaucrat within the Social Security Administration for many years before retirement. Until a few years ago, the Social Security Administration handled hearings in Medicare cases. I have seen the process from the inside and I have very strong doubts that the government would be equally efficient as insurance companies. I have seen much inefficiency and outright stupid decisions. The fact that LeisureGuy has not had any problems with the administration of his Social Security payments does not mean much because he is a very small sample. I have seen administration of Social Security payment of all kinds get messed up royally.

  4. Michael, thanks for your fine comment. You clearly have credibility on the issue. You are quite right that it is vexing to define an unnecessary medical test. Any test will be defined as necessary by someone.

  5. Your solicitor will need a medical report providing an opinion on whether medical negligence has been committed. This report alone can cost upwards of 1,000 pounds. After this report, if the expert believes there is a claim, further evidence will have to be obtained by the solicitor. It is not uncommon for the costs in medical negligence claims to run into tens of thousands of pounds, so it is important to consider what your options are for funding a case. You can still obtain legal aid for medical negligence claims. It is not necessarily easy to achieve, but if you do obtain legal aid, the Legal Aid Board will fund your case although if you are successful, they will expect to recover any costs paid. For more details visit us at Medical Negligence Solicitors.

  6. HCR Opponents Say..HCR Supporters Say

    Unfortunately, this B&W thinking is what led to the passage of the ACA.

    The mendaciloquence and redaction of facts on the part of both sides prevented focusing on discussing coverage based on an emotional argument vs. society's allocatur. Is that not the reality?

    Most have the maturity to know that health care is not illimitable but the arguments were never presented cleanly.