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Health Care rationing-- let's talk reality

 
 
Reply Sun 9 Aug, 2009 09:49 pm
Lets talk about health care rationing (which the Republicans are now busy trying to equate with Nazism). Actually, health care rationing is a necessity. The current system has health care rationing, any health care plan the Republicans have come up with has health car rationing),

Our current system rations care through limits put on you by the insurance company based on what and how much they will pay. If you don't have insurance (of course) your health care is severely rationed. There is a random element that has to do with the insurance companies efforts to find loopholes to avoid paying for your care.

We can do much better than our current system. But, since there are more and more expensive treatments, and a finite amount of dollars to spend. There is simply no way around rationing care.

The question is how to ration care ethically (according to the values of our society for anyone who want to attempt a cross thread pounce) and rationally.

Some points to start the discussion.

1) There is a real limit to the amount of our GDP we can spend on health care before it becomes unsustainable. Our healthcare spending is increasing much faster than our GDP meaning we are approaching this limit.

2) Every dollar spent treating a terminal patient is paid for by healthy Americans. Under a private system-- it is paid by rate payers (raising premiums). In a public system, it is payed by taxpayers.

You lower costs in any system by spending less on treatment.

2) The extremes seem obvious--

I am quite sure that we all agree that spending $100,000 to extend a life 20 years is well worth it. I am interested to know if anyone thinks that spending $20 million on extending a life 5 months is worth it.

The question seems not whether to ration care, but how to do it fairly.

Rationing health care is part of living in a modern society. We do it now... and we will do it in any health care system I have ever heard of or imagined.

A reasoned discussion on how to deal with these issues would be a good thing... unfortunately it is a political third rail-- meaning we will live with the myth that there is enough money to keep everyone from dying.

All I know is that profit-motivated health care has failed in many areas, including providing a rational policy on health care decisions.
 
marsz
 
  0  
Reply Mon 10 Aug, 2009 01:09 am


Rationing care from limited funds


Some cancer treatments are not available

The NHS cannot, and never has been able to, offer every treatment to everyone who needs it.
The NHS is funded from taxes, and it spends more than £42bn every year - £779 for every person in the UK. But it is not a bottomless pit of funds and some treatments have to be restricted.

Raising taxes to pay for every possible need is politically unthinkable, as it would require a massive increase in income tax to raise enough revenue to make a significant difference to spending.

This means some treatments have to be restricted, or rationed.

The media hype over the anti-impotence drug Viagra forced the issue out into the open.

The government has restricted the circumstances in which people will be prescribed the drug.

Responsibility

The British Medical Association wants the government to accept responsibility for rationing decisions and to consult the public over which treatments should be restricted on the NHS.

This would require a national policy - at the moment health authorities make the decisions on drug rationing on an individual basis.

This leads to accusations that care is being delivered by postcode since patients living under one health authority are denied a treatment available to those living under another.

The issue of rationing has also come to the fore due to the setting up of primary care groups later this year, when GPs will take over responsibility for commissioning care for their patients.

In a January 1999 survey of GPs, conducted by Doctor magazine, one in five said they knew patients who had suffered harm as a result of rationing.

More than 5% of the 3,000 surveyed also said they knew of patients who had died as a result of being denied treatment on the NHS.

Expensive treatments

One of the most controversial rows over rationing concerns beta interferon, a treatment for multiple sclerosis.

The full effectiveness of the drug has yet to be established, and because it is very costly - approximately £10,000 per patient per year - some health authorities are reluctant to allow doctors to prescribe it.

Another example is a drug used in the treatment of ovarian cancer, Taxol, which has been licensed for use in the UK since mid-1998.

It costs £1,500 per injection and the average course requires six of these.
There are two studies that show the drug extends a patient's life by a year, but this is not enough evidence to justify prescribing it for everyone with ovarian cancer.

Marilyn Bush had the disease but was able to get the treatment because her private health care insurance agreed to pay for it.

She said: "Could you imagine how you would feel if you knew you could not possibly find the money for a drug you needed?

http://news.bbc.co.uk/2/hi/health/251988.stm
Walter Hinteler
 
  5  
Reply Mon 10 Aug, 2009 01:27 am
@marsz,
Any newer reports than that of 2003, marsz?

And why do you refer to the NHS? Is that's the model which is thought about in the USA? (You can, of course, get additional private health insurances in the UK, too.)

0 Replies
 
Foofie
 
  1  
Reply Mon 10 Aug, 2009 07:05 am
@ebrown p,
ebrown p wrote:

I am quite sure that we all agree that spending $100,000 to extend a life 20 years is well worth it. I am interested to know if anyone thinks that spending $20 million on extending a life 5 months is worth it.

The question seems not whether to ration care, but how to do it fairly.



No. The question is also how to mass produce the benefits of health care, like Ford's Model T assembly line, so the unit cost comes down. The other day I saw an FM earplug type radio for $1.00. In the mid-50's a transistor radio cost around $35 dollars. The dollar being worth more then, could equate to over $200 dollars today, possibly. So, the cost came down, perhaps, to .005 (one-half of one percent) of the original cost, based on a dollar's value then and now. The concept of rationing expensive health care just allows the inefficiencies of the system to continue. The key might be to educate the health professionals with government subsidized education, and turn health facilities (aka, hospitals) into non-profit entities. In my opinion, health insurance companies could just be the whipping boy to this debate. There are more problems than the media seems to be focussing on.

The public is once again being led in only one direction. The problem is multi-directional.
ebrown p
 
  1  
Reply Mon 10 Aug, 2009 08:09 am
@Foofie,
I don't understand at all your point about mass production. Not only does it not have anything to do with health care rationing-- it also seems that mass production has been a great benefit to products-- making high quality items at a much lower cost. Do you have a car that wasn't mass produced? But lets get back on topic.

Do you agree that spending $100,000 to extend a life 20 years is worth it?
Do you agree that spending $2 million to extend a life 4 months is not worth it?

It seems to me that the extreme cases are obvious (i.e. most rational people will agree).The question is how to come up with rational policy for the often difficult cases in between these two extremes.

I don't think a system based on corporations motivated by profit is a good way to make decisions about who gets health care. Decisions based on maximizing profit are often not the best decisions for patients or for society at large. We will gain a lot by taking the profit motivation out of our health care decisions.

Countries with a public health care system have higher life expectancies, lower birth mortality rates-- all while paying much less money.

Walter Hinteler
 
  1  
Reply Mon 10 Aug, 2009 08:17 am
@Foofie,
"Mass products of the benefits of health care" - well that might the free prevention courses in spas, gyms, etc?

Or the prescription of geriatric pills?

Or that the the pharmaceutical industry has contracts with some or more health insurers about a discount price for some of their products?

(All such is done here in variations or together.)
rabel22
 
  1  
Reply Mon 10 Aug, 2009 08:21 am
@ebrown p,
You dont understand conserative thinking. I have my afforadable medical insurance so I dont give a damn if any else has it. I am not willing to spend 10 or 20 dollars extra for someone elses insurance. The christian attitude goes by the board by many when it is compared to money. Not the fault of religion but peoples greed.
0 Replies
 
Foofie
 
  1  
Reply Mon 10 Aug, 2009 06:05 pm
@ebrown p,
O.K., you do not understand my point. I am comfortable with that.
roger
 
  1  
Reply Mon 10 Aug, 2009 06:09 pm
@Walter Hinteler,
What sort of geriatric pills are we talking about here?
0 Replies
 
Merry Andrew
 
  1  
Reply Mon 10 Aug, 2009 06:28 pm
@Foofie,
I have a feeling none of us understand your point, Foofie. I certainly don't.
0 Replies
 
slkshock7
 
  1  
Reply Mon 10 Aug, 2009 08:34 pm
@ebrown p,
ebrown wrote:
Do you agree that spending $100,000 to extend a life 20 years is worth it?
Do you agree that spending $2 million to extend a life 4 months is not worth it?


On the first, yes,
On the second, no, especially if its my life we're talking about here. What gives anyone the right to tell me whether four months of my life is worth $2M or not?
ebrown p
 
  1  
Reply Mon 10 Aug, 2009 09:00 pm
@slkshock7,
Quote:
What gives anyone the right to tell me whether four months of my life is worth $2M or not?


You are asking them to pay the bill (under either a private or public health plan).
0 Replies
 
marsz
 
  -1  
Reply Mon 10 Aug, 2009 10:19 pm
The British Health System ----------------------Quality-adjusted life years
NICE utililises the quality-adjusted life year (QALY) to measure the health benefits delivered by a given treatment regime. By comparing the present value (see discounting) of expected QALY flows with and without treatment, or relative to another treatment, the net/relative health benefit derived from such a treatment can be derived. When combined with the relative cost of treatment this information can be used to form an Incremental Cost-Effectiveness Ratio (ICER) to allow comparison of suggested expenditure against current resource use at the margin (the cost effectiveness threshold). [6] As a guideline rule NICE accepts as cost effective those interventions with an incremental cost-effectiveness ratio of less than £20,000 per QALY and that there should be increasingly strong reasons for accepting as cost effective interventions with an incremental cost-effectiveness ratio of over £30,000 per QALY.[9]


Cost per quality-adjusted life year gained
The cost of a treatment may be relatively easy to calculate but because people may be at different ages when they receive treatment, the gain may be different according to age. A heart operation on a small child may deliver many more years of quality of life than the same operation on a 76 year old man. By taking the cost of treatment and dividing it by the years gained an overall cost benefit ratio can be determined as the 'cost per quality-adjusted life year gained' or CQG.
Wikipedia.

This means that if you are 76 years old, you cannot extend your life by six months since it costs too much.

Not for my mother or father if I can help it.
marsz
 
  0  
Reply Mon 10 Aug, 2009 10:24 pm
Q:
How is the German healthcare system funded?


A:
Until they reach the retirement age of 65, people must, by law, pay into health insurance plans (and, since 1994, an additional long-term care plan). The health insurance plans are either state-regulated or private. After retirement, contribution payments for the state-regulated plans stop (although private patients continue payments), but coverage is continued until death.

Only certain groups are allowed to take out private health insurance. The vast majority of people are obliged to use state-regulated plans and, depending on their individual circumstances, choose from one of about 400 options. The government regulates the fees of state-regulated plans. Although some doctors take only private patients, normally every doctor has a sign that says s/he is accredited by all insurance providers.

There are several types of state-regulated plans. Some large companies and guilds offer their employees in-house plans. Other groups " notably people working in technical and scientific environments, employees in medium-sized and small firms, or blue-collar workers " often prefer the so-called self-governing substitute plan (Ersatzkassen). The state covers health insurance contributions for the unemployed and those with low income.

Contributions to the state-regulated health plans (currently around 14% of the employee's gross income and shouldered equally by the employee and the employer) cover up to 68% of overall healthcare costs. Income taxes, funds derived from those with private health insurance, and out-of-pocket payments (e.g., for prescriptions where the insurance covers only 90% of the charges) attempt to cover the remainder.

The government regulates the use of private insurance. There are three main types of people who use private insurance plans. Persons with a monthly income exceeding US$3,825 may legally opt out of state-regulated plans and switch to private insurance. The self-employed are excluded from the state-regulated plans and so must take private insurance. Public sector employees (e.g., police, teachers) are reimbursed for part of their health costs by the state but have to be privately insured to cover the rest. (The government is now trying to make it difficult to opt for private insurance because the state-regulated insurance loses the 14% contribution from these high-income earners.)

Currently, the seven million patients insured by the 52 private health insurance providers are billed directly by physicians, dentists, and hospitals, and are reimbursed by the insurance companies. Doctors may charge higher fees for private patients and it is at the insurer's discretion to refuse to cover unreasonable amounts.

Both types of insurance cover physician fees, hospital fees, chronic care, and part of dental care. Patients within the state-regulated insurance plans may consult any general practitioner or specialist officially contracted and recognized by their insurance provider. The doctor then settles the fees directly through the insurance provider. Hospital bills for diagnostic tests, treatment, and drugs are settled directly between the insurance providers and the hospitals. In order to keep costs down, the government is forcing the powerful pharmaceutical firms to give insurance providers a higher discount on medicines.


Q:
What is the quality of care in each system?


A:
In the WHO's year 2000 report for global healthcare, Germany ranked 25th out of 191 countries based on a cost/effectiveness ratio (the USA came 37th and Canada 30th). Although some hospitals have certain wards designated solely for the use of private patients, people in state-regulated insurance plans and those with private insurance use the same hospitals. On the whole, patients who are not privately insured are at no medical disadvantage and receive the same standard of care as the private patients.

Generally, doctors work either in hospitals or in private practice. Those working in hospitals are employed by the hospitals. Those working outside the hospitals have their own offices and are self-employed (these include general practitioners and specialists, e.g., gynecologists, internists, homeopaths), but they all refer patients to a hospital if necessary. Some of the specialists " notably gynecologists and ENT surgeons " have "reserved" beds in a hospital, where they perform operations and visit their patients, leaving the rest of the care to the hospital staff.

Apart from relatively minor delays for non-emergency surgery (e.g., three to four months for hip replacements), waiting times are virtually non-existent.


Q:
What are the current concerns among healthcare workers in the country?


A:
To keep costs down, the government has frozen hospital workers' salaries for the year 2003. Also, government legislation imposing strict limits on hospital expenditure and the number and type of medication practitioners are allowed to prescribe, has fuelled fears that healthcare workers will leave the country, resulting in generally lower standards at home. Recently, there have been scandals involving doctors who bill insurance companies for treatments that they never performed, and there has been an increase in malpractice (especially in the ORs). In eastern Germany, many new practices have high debts and face insolvency, which undermines provision of healthcare.


Q:
What are the current concerns among patients?


A:
A lack of screening facilities for the early detection of breast cancer makes Germany fall well behind European standards. Also, Germany's underdeveloped palliative care system provides only 12 beds per one million inhabitants. Other weak points of the system include a lack of co-ordination between inpatient and ambulatory care and, at best, fragmented support from the social services departments.

Patients currently perceive healthcare in Germany " despite its generally excellent results " as being in a crisis and fear that it is turning into a "two-class system" whereby the rich would be able to buy private, comprehensive, quality healthcare but those legally bound to the state-regulated schemes would receive only basic healthcare.

http://www.medhunters.com/articles/healthcareInGermany.html
Walter Hinteler
 
  2  
Reply Tue 11 Aug, 2009 01:59 am
@marsz,
Thanks for that -kind of- "historic" report (we are in 2009 now).
0 Replies
 
Walter Hinteler
 
  1  
Reply Tue 11 Aug, 2009 02:01 am
@marsz,
marsz wrote:

This means that if you are 76 years old, you cannot extend your life by six months since it costs too much.


I'm friendly with a couple of over 76 years old: they praise the NHS-system and what it does for them ...
0 Replies
 
Walter Hinteler
 
  3  
Reply Tue 11 Aug, 2009 10:19 am
Interesting opinion in the Investors Daily: How House Bill Runs Over Grandma

Quote:
People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.


oops? Born in London, went to school in St Albans/Hertfordshire, studied at University College, Oxford, is the Lucasian Professor of Mathematics at the University of Cambridge, lives (around) there, his "health insurance" is by NHS Cambridgeshire ...

Quote:
In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer.


Yes, like all over Europe. Authorities here think, it's still too dangerous.
It's only allowed in some clinics .... where it still is tested (GlaxoSmithKline agreed to do more tests, too.)
0 Replies
 
rabel22
 
  1  
Reply Wed 12 Aug, 2009 09:54 am
I was reading an article about the 156billion that HMO's get from the government above the cost of insurance for seniors. This person was claiming that if the government took this money from the hmo's they would suspend coverage in some areas. Well ive got news for you. In the county in which I live NO HMO's have have ever offered medicare coverage to seniors, nor in most of the adjesent counties. Not enough profit to be made so they say.
0 Replies
 
czar
 
  1  
Reply Fri 21 Aug, 2009 08:46 am
Do you think that if there is healthcare rationing that they will ration like they do with medicaid
ebrown p
 
  1  
Reply Fri 21 Aug, 2009 11:02 am
@czar,
Please explain.... how do they ration with medicaid?
0 Replies
 
 

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