Undernews is the online report of the Progressive Review, edited by Sam Smith, who covered Washington during all or part of one quarter of America's presidencies and edited alternative journals since 1964. The Review has been on the web since 1995. See main page for full contents

July 29, 2009


Sam Smith - One of the reasons the Democratic health care plan is so controversial is because the party and its president want to use corporate economic principles to decide how healthcare should be distributed.

The problem with this is that human beings are not corporate structures. They have souls, loves, hopes, imaginations - not to mention friendships and relationships - that can not be priced or measured for cost effectiveness.

The Democrats are, admittedly, late comers to the terminally sick principles of longevity economics. After all, they had to overcome all those centuries of theologians and philosophers, not to mention their own liberal forebears, who taught us to value life without putting a dollar amount on it. And they had to ditch their own traditional principles, including the one that said that each of us should be equal to all the others.

But that was before the bipartisan fiscal disaster with which we are now faced. And so on one recent week, the Democrats in the Senate rejected three Republican attempts to bar the rationing of care under the new health bill.

The Democrats have belatedly lopped onto a theory that includes the notion of a "quality adjusted life year." As Wikipedia puts it, "The quality-adjusted life year is a measure of disease burden, including both the quality and the quantity of life lived. It is used in assessing the value for money of a medical intervention. The QALY model requires utility independent, risk neutral, and constant proportional tradeoff behavior. The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or be confined to a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this."

I have a little experience with this. Sixteen years ago I came down with prostate cancer. The web was in its infancy, but I still managed to pull down data from various sources and construct myself a flow chart that analyzed the advantages and disadvantages of various approaches. As I did so, I realized that the math would only take me so far. In the end, I settled on surgery, not because it was definitely the best solution, but because it was the best one I could best live with.

If I had, for example, taken the watch & wait approach, there might have been one of two results: the cancer might have increased, perhaps to the point of it becoming far more serious, or I could have lived with sixteen years of constant, unnecessary worry because that's the sort of guy I am.

Things like worry, or a disease's affect on others near to the patient, don't enter quality life calculations. And there are other problems, well summarized in 1990 in the abstract of an article by John La Puma and Edward F. Lawlor in the Journal of the American Medical Association:

"Quality-adjusted life-years have been used in economic analyses as a measure of health outcomes, one that reflects both lives saved and patients' valuations of quality of life in alternative health states. The concept of "cost per quality adjusted life year" as a guideline for resource allocation is founded on six ethical assumptions:

- quality of life can be accurately measured and used

- utilitarianism is acceptable

- equity and efficiency are compatible,

- projections of community preferences can substitute for individual preferences,

- the old have less 'capacity to benefit' than the young

- and physicians will not use quality-adjusted life-years as clinical maxims.

"Quality-adjusted life-years signal two shifts in the locus of control and the nature of the clinical encounter: first, formal expressions of community preferences and societal usefulness would counterbalance patient autonomy, and second, formal tools of resource allocation and applied decision analysis would counterbalance the use of clinical judgment.

"These shifts reflect and reinforce a new financial ethos in medical decision making. Presently, using quality-adjusted life-years for health policy decisions is problematic and speculative; using quality-adjusted life-years at the bedside is dangerous."

The Democrats claim they won't be rationing anyone, but the minute budgets take precedence, rationing is only a short distance away. What, for example, if I had come down with prostate cancer after the bill was passed? And what if surgery in my case was permitted but only with a payment equal to a small fraction of the cost? On the other hand, what if watch & wait was the approved method and fully funded? Which would I take and who would have then done a cost effectiveness study of my 16 years of worry? And what role would my doctor play in all of this?

I know I'm sharing political ground with the conservatives on this one. But it's not my fault that Obama and the more powerful Democrats are acting like a bunch of money grubbing corporate CFOs while some Republicans are playing a role normally associated with progressives, which is to say that you don't discriminate against people because they are too something . . . in this case too old or too sick to pass a cost effectiveness test.

But these are crazy times and I'm at least happy to still be around to bitch about them thanks to the fact that sixteen years ago my doctor and I were able to make a decision based on our choice and not what on what some group of government experts thought was best for me and next year's budget.


Heritage Foundation
- Comparative effectiveness research, which is research that compares the clinical and/or cost-effectiveness of two health care treatments for the same condition, has been a contentious topic since the giant stimulus bill provided government agencies with $1.1 billion to conduct it. The Kennedy bill includes an increased role for CER. How this language is to be interpreted is crucial.

There is nothing wrong, of course, with finding out what works and what doesn't. The key issue is the consequence of the research findings for patient care, and whether those findings come with any regulatory or reimbursement strings attached to them. If CER can be used by the government to make payment, treatment, and coverage decisions, it could also be used as a rationing tool. Recently, the Senate Committee considered and rejected three amendments that were designed to prevent CER from becoming any such thing.

As The Washington Post pointed out on June 8th, one of the key issues emerging in the national health care debate is whether or not there will be official limits on the kinds of care, medical treatments, or procedures that Americans can get. As The Post reporter noted, when asked a specific question on this issue, the President failed to respond.

The President has stated, repeatedly, that if you enjoy your relationship with your doctor, his proposals would not interfere with that relationship. However, if CER becomes a pretext for rationing, government policy would, in effect, destroy the doctor-patient relationship. It would not only devalue a physician's professional judgment in a particular case, it would also amount to a violation of the traditional Hippocratic Oath. The traditional Oath, after all, holds that the doctor is a servant of the patient.

Heritage Foundaton, December 2008 - During the presidential campaign, Obama proposed the creation of an institute that would judge the "comparative effectiveness" of medical treatments, procedures, and therapies, as well as drugs, devices, and technologies. Baucus has also called for the creation of such an institute. More recently, Daschle outlined in much greater detail a similar proposal for a congressionally created Federal Health Board modeled on the Federal Reserve Board, with a governing body of politically appointed experts but "insulated from politics."

In Daschle's version of this new public agency, its "experts" would "oversee the health care industry" and have the knowledge and power to make "complicated medical decisions and the independence to resist political pressures." Additionally, these government experts would "help define evidence-based benefits and lower overall spending by determining which medicines, treatments, and procedures are most effective--and identifying those that do not justify their high price tags." This means denying payment. The health board would also:

- Set the rules for health insurers who would participate in a national health insurance exchange and recommend benefits coverage, including drugs and medical procedures backed by "solid evidence";

- "Rank" therapies and medical services based on their cost effectiveness;

- Suggest priorities for medical research;

- "Align incentives with the provision of quality care," as defined by the health board, through Medicare-style "pay for performance" rules for doctors and other medical professionals who comply with government practice guidelines.

Daschle is frank and forthright about the enormous power of his proposed Federal Health Board. Such a body, he admits, would alter the traditional doctor-patient relationship. "Doctors and patients might resent any encroachment on their ability to choose certain treatments," he says, "even if they are expensive or ineffective compared to the alternatives."

Jeffrey Lord, American Spectator - So. Who will tell Michael J. Fox he needs to die?

Which health care mouse out there will have the guts to bell the cat who is one of the most famous Parkinson's Disease sufferers in America? Who is going to tell him that the treatments that are associated with Parkinson's -- drugs like Sinemet, Symmetrel, Eldepryl, Parlodel, Permax, Mirapex, Requip, and surgery with the quaint name "deep brain stimulation" -- are just no longer possible for Fox because, well, Mike, your QALY just isn't up to snuff, babe. . .

Elizabeth Taylor. La Liz. Born in 1932, her age alone raises the appropriateness question She's had more health problems than husbands, as one BOD Squad staffer apparently scribbled on a report. Are you kidding? The Secretary of the Department (known internally as the SOD BOD) was furious to see what the American people had been putting up with from this woman: Congestive heart failure, a benign brain tumor, skin cancer, a back five-times broken, both hips replaced, bouts with pneumonia, osteoporosis and scoliosis. In the succinct observation on her leaked file: "Toast." Say hello to Jacko.

David Letterman: A quintuple bypass was given to Dave. That was under the old pre-Obama system and it won't be allowed again. Dave's QALY is nowhere near that of a healthy teenager who might have a case of pneumonia that is cheaper to treat and not likely to recur. . .

Patrick Swayze: As this is written, the National Enquirer is on the stands proclaiming this famous cancer victim has had a heart attack. According to news accounts, Swayze has been undergoing "pioneering Cyberknife radiotherapy at California's Stanford University Medical Centre." Cool. But alas this kind of thing doesn't meet the BOD Squad standards for appropriate or effective treatment. . .

Magic Johnson: Eighteen years ago, the legendary Los Angeles Lakers star had to quit because he contracted the AIDS virus. He is still here, healthy and active at 50. The problem: every day Magic has to swill a "multidrug cocktail" of GlaxoSmithKline's Trizivir and Abbott's Kaletra to keep himself healthy. . .

Larry King: CNN's talk star suffered a heart attack in 1987 and had quintuple bypass surgery. . . Who cares if Larry has a Foundation? Do we really need more heart attack books? Sorry Larry, if the BOD Squad had been here in 1987, you wouldn't be. . .

Regis Philbin: Regis had a triple-bypass at 75 years of age, after having an angioplasty fourteen years earlier. Seventy-five? Whoa. There's no QALY statistic in the world that will say these resources were better used on Regis than on some 21-year-old. Regis, buddy. What were you trying to pull? . . .

Melinda Beck, Wall Street Journal - As lawmakers battle over how to expand coverage for more Americans and how to pay for it, an equally contentious issue is looming: Many experts, doctors and politicians want to revamp the U.S. health-care system to reward the quality of care. That's a big departure from the decades-old practice of paying medical practitioners for the quantity of services they provided. It could mean fundamental changes, philosophically and practically, to a system that has long allowed doctors great leeway to use their own medical judgment and has given many patients the luxury of not having to make treatment decisions based on cost. . .

The government is making a big push for data that compare which treatments, tests, drugs and procedures work for a wide variety of conditions, known as comparative-effectiveness research. Experts inside government and out have been slowly collecting such information for years, much of it under the auspices of the federal Agency of Healthcare Quality Research, or AHRQ. This spring, Congress allocated $1.1 billion in stimulus funds for the effort, and the government's influential Institute of Medicine recommended 100 health topics that should get priority attention, from remedies for back pain to preventing falls in elderly.

Many doctors welcome the information as a way to inform their own decision making, assist patients who want to research their own conditions and help counter the power of pharmaceutical marketing to drive medical choices. A coalition of 62 medical associations has endorsed the comparative-effectiveness effort, noting that in some cases, such research could help identify high-quality, low-cost treatments, and in others, it could help persuade payers and providers that expensive new technology is worthwhile.

Some doctors say the government must be wary of drawing broad conclusions for large groups of patients. "If they are going to establish that prostate cancer grows so slowly that few men will die from it and therefore screening is not helpful, that would be a devastating situation for a lot of men," says David Samadi, who performs robotic surgery at New York's Mount Sinai Medical Center. He notes that 27,000 U.S. men die each year from prostate cancers, some of which are aggressive.

Elizabeth Lee Vliet, a women's health physician in Tucson, Ariz., notes that much medical data don't differentiate between women's and men's genetic and hormonal makeup. She points to the conclusions initially drawn from the Women's Health Initiative, which prompted millions of women to stop taking hormone-replacement therapy, even though later analyses found that HRT was a net gain for women who started shortly after menopause. . .

Conservative critics fear that comparative-effectiveness research, also known as evidence-based medicine, will ultimately be used to justify rationing health care-and that the elderly could be most vulnerable. Under the U.K.'s single-payer system, the National Institute for Health and Clinical Effectiveness makes coverage decisions based on "quality-adjusted life years"- taking into account a patient's life expectancy. . .

As it is, Medicare rates are set by Congress and are subject to intensive lobbying every year. New treatments that provide a "net value" are approved without regard to cost. . .


Blogger robbie said...

The Heritage Foundation and the American Spectator? These are some of the people responsible for the need of a massive health-care overhaul.

July 30, 2009 8:49 AM  
Anonymous Anonymous said...

Actually, the likes of Fox, Swayze, Taylor and the other people of fame and fortune will not suffer under this plan because of who they are, their wealth and their connections. It's the everyday slugs like me and you that will have to deal with a Govt idiot making the decision if you live or die. Personally, they can shove this plan where the sun doesn't shine.

August 6, 2009 6:55 PM  

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