nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Wednesday, March 10, 2010

Not Death Panels, but "Cut-Our-Losses" Panels
UPDATE:  Some grammatical and phrasing changes for clarity

Some of you probably heard about the Canadian Provincial Governor who came to the US last month to get his heart surgery done.  Some thought it a reflection on availability and quality of health care in Canada.  There was never any clear documentation for his reasons, although about a half-million Canadians are awaiting surgery, and several hundred thousand are awaiting referral for specialty care--by the government's own estimates.

But this case (click on the link) reported in the Toronto Sun (Mar 6) is a good example of how Comparative Effectiveness standards (touted by President Obama and the Democrats) would work.  A panel would judge whether any one treatment, or no treatment, would be the most effective.  And cost is always a part of this effectiveness review.  Cost is tied to what resources are available and how much value, in terms of survival or quality of life, a give treatment will likely provide.  In this case, a man with brain cancer was effectively denied surgery in Canada while the government studied whether his surgery would justify the cost.  Cancer is a time-sensitive illness.  Desperate and worried, he traveled to the Mayo Clinic at his own expense to get the surgery.  Upon his return, the government denied him coverage for the follow-on chemotherapy agent, once again based on whether it would effectively prolong his life to such an extent that the high expense of the drug (on the order of $9K per month) was justified.  Once the case reached the news media, provincial officials and national officials began pointing fingers at each other, claiming "not my fault."




This is not the first issue of this type in Canada:  Herceptin for breast cancer was another controversy.  Nor is Canada the only single-payer with this problem.  Europe, Great Britain in particular (drug-eluting stents for coronary artery disease), also are experiencing similar conflicts.

I recommend the article for the administrative decision-making process that unfolds when trying to make rational decisions about individuals' lives.  Understand clearly, that in a rational, centrally planned health care system, the Canadian review board made the right call.  It cannot afford to spend $100K on an operation, and another $100K on drug treatment for a case where survival may be poor.  That $200K could be used more effectively to save a number of lives from auto accidents, or treat other conditions that can be cured but are less costly.  In effect, they cut loose one person to save others (potentially).  It's like triage in a disaster casualty management scenario; resources are limited and the need is greater than can be met, so you prioritize to the maximum benefit of the whole. 

If this thinking is starting to sound familiar, you're right.  Experts have argued about the "utilitarian calculus" for 300 years at least (John Stuart Mill, Jeremy Bentham, Karl Marx).  But before we vilify these approaches to maximum benefit as being cold, calculating, impersonal, and unfeeling, let's recognize that in our country people are cut loose from the health care system, too.  Only it's done here by price.  If you can't pay, you're outta luck.  We have safety nets, but they don't give the same benefit and quality that everybody else gets.

On the other hand, there are differences too.  We don't penalize those who choose another option for their care.  You may want only catastrophic coverage, or a Cadillac plan, or none at all.   In Canada's single payor system, practically speaking, there aren't any other choices. The system is funded through taxation.  By contrast, their private health care system is almost non-existent, and not for the non-wealthy.

The US has traditionally preferred freedom of choice, and tried to secure the safety of the lowest economic stratum through separate legislation (Medicare, Medicaid, WIC, etc).  The health care reform proposals will change that.  And, when you come down on one side or the other on the debate, it's important to recognize that both approaches have their good and bad side, and each is imperfect.

Resources are always limiting, so ask yourself this:  what makes you more uncomfortable, that some people have less access to healthcare, or that you personally, and others, may run up against a decision about your care that is not what you would choose (a different medicine, or surgery, or even denial of care)?  Said another way, are you willing to accept a cost-benefit decision that may not be what you, or others, want (or need) for the moral good of ensuring others the same access?

Answer that, and you'll learn something about yourself.

Doc  D

Opinions are entirely my own

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