Tuesday, February 16, 2010

Good care, cheap care and secret decision-making

It seems a simple choice.

If you have an abdominal aneurysm - a bulge and weak spot in an artery - there are two treatment options.

Doctors can cut you open from breastbone to hips, push your organs over and sew in a plastic tube to replace the weak spot. After a week or so in hospital, you face a long recovery.

Or they can make a small incision in your groin and insert a stent - a little compressed metal mesh tube - into the artery and then slide it into place and expand it. A day or two in hospital and you’re as good as new.

Personally, I’d like option two. That’s what Bill Clinton had last week and he was home the next day.

But for health authorities it’s complicated. And a dispute between vascular surgeons and the Vancouver Island Health Authority is opening the door on the world of health care rationing. It’s not pretty.

The surgeons want to do more of the stent procedures. The health authority wants to control costs so it sets a quota on the number on them - 38 this fiscal year.

The surgeons are supposed to manage so that about 100 patients get the traditional surgery and the 38 people at greatest risk of complications get the stent treatment.

The surgeons got so frustrated they went public. Patients who needed the stent surgery were being made to wait because of the quota, they said. Patients said they felt the authority was playing Russian roulette with their lives. An aneurysm can burst without warning.

And, the surgeons said, the costs are the same if you include the extra time in acute care beds required by patients who undergo the traditional surgery.

It gets interesting here.

VIHA costs the traditional open surgery at about $1,500. A nurse, anesthetist and surgeon.

A stent procedure, it figures, costs $19,500. The little mesh tubes, perhaps an inch long, cost about $13,000 each. The surgeons say you can’t just look at operating costs. As well as being better for high-risk patients, the stent procedure means about a week less in hospital, so the real costs are in the same range.

The authority’s response explodes a health care myth. We tend to think care is limited by hard factors — too few beds or nurses, not enough MRI scanners.

VIHA said the savings from having patients spend a week less in hospital aren’t real. Some other sick person would just occupy the bed and the money would still be spent.

The health authority, because of the funding from government, needed that sick person waiting at home, not getting care.

Logically, the correct response would be to do the stent procedure and then leave the bed vacant for a week. The cost would be the same and the patient would be better off.

But that wouldn’t happen. People could accept their child waiting for needed care because there just wasn’t a bed. But not to meet an arbitrary budget quota.

The health authority said the doctors were being unreasonable, perhaps unprofessional, in seeking to use the stent surgery when it wasn’t warranted.

The surgeons said they limited the use to necessary cases and the arbitrary cap was foolish and dangerous. They had tried to work with the health authority to come up with a rational approach and been turned down.

And the public got a jarring look at health care. Even if you don’t know who is right, this process looks ridiculous.

It’s not just VIHA. The Fraser Health Authority went through a similar dispute last year.

And it’s not just stents. A wide range of cuts and rationing are being made without clear rationale, the support of doctors or any public discussion.

Ultimately, that’s the biggest concern. The government sets a funding level and the health authorities make life-and-death decisions about service levels behind closed doors.

And the public is left far on the outside.

Footnote: Stents are gold for the companies that have the patents. As all this was being reported, Boston Scientific Corp. said it would pay Johnson & Johnson $1.7 billion to settle a stent patent dispute. The two companies sell about $2 billion worth of stents a year; globally it’s a growing $7 billion a year business.


Anonymous said...

Very interesting - this is the kind of revelation that Fox News would have a field day with - and rightly so!

But the cost of the stents is the real issue here. I appreciate that you need patent protection to provide an incentive to the innovators who come up with these things, but high-powered corporate lobbying has encouraged governments to take it way too far. Some of the greatest innovations come from people who have been motivated by curiosity and a quest for excellence, not money, and that would continue to happen if governments restored some sanity.

off-the-radar said...

and obviously patient care and recovery are not VIHA priorities---its just one body in a bed or another, so the "bottom line" cost fpr VIHA remains the same.

Yet another reason why accountants shouldn't run hospitals.

Anonymous said...

The Olympic Athletes Village cost approximately $1,000,000,000 - enough to pay for 50,000 stent procedures (at $20,000 each).

The cost of the Sea to Sky Highway upgrades at $650,000,000 would be enough to pay for another 32,500 stent procedures.

Another $1,000,000,000 squandered on Olympic security might have paid instead for another 50,000 equally expensive surgeries or hospital visits.

The Vancouver Convention (oh I forgot that isn't an "olympic cost") another 50,000 such procedures.

Do you still recommend we suck it up and just enjoy the games Paul. You were absolutely right when you pointed out we've paid for them anyway - but I think you overlooked that some were paying in blood.

More hundreds of millions for a football stadium roof? No problem.


DPL said...

The present governemnt in BC has priorities but sick people arn't anywhere near the top of the list. Sad for the folks who are in a like or death situation waiting for others to die so they can move up the wait list for a shunt. Who votes for those clows anyway?
Le'ts not forget the 135 million spent to " Own the podium" I'd prefer to see a few extar folks live through a serious operation.

The Patient Factor said...

Our current health care system is failing both patients and providers. The patient voice must be heard. It is time to ask questions, seek answers, contribute ideas and drive change.

RossK said...

Kudos to Raymond, above, for doing the math.

It's powerful, that long division, eh?


healthnutdoc said...

I find it surprising that you are surprised that hospitals are rationing care. Rationing of health care has been present since the early 1980s after runaway health costs required the insertion of hospital administrative teams in order to control soaring expenses. These expenses had come during the Trudeau economics years of the 1970s after the widespread adoption of Medicare; physicians no longer had to discuss with their patients the most affordable treatments but could merely ask patients what they wanted and then advocate for their personal interest, charging the cost to the public. This strange concept still is in evidence today.
Hospital and health financing comes from the public tax burden. Governments provide Health Authorities with a fixed sum of money each year with which to provide the necessary services to the public under their care. I need to repeat that the word is “necessary”, not “preferred” or “desired” or “that which is currently considered fashionable”. The Canadian system operates next to the American system and Canadians expect a style of care similar to that paid for by individuals rather than governments. The Canadian system should more accurately be compared to the European or Australian or New Zealand systems. Canada performs well in those comparisons
However, the real issue underlying your recent blog is not so much that of rationing of scarce resources but the impertinence of expecting the public system to provide a person with what he/she wants rather than needs. The Canadian public system is well able to supply the needs of the majority of its public. However in the case of expensive technology, especially expensive technology that improves patient convenience, those who must administer the public purse are challenged on providing services to a few individuals, when redistribution of those resources can treat many who need care.
With respect to abdominal aneurysms a patient's needs can be well met via elective aneurysmectomy. It is recognized, however, that some people are at such high risk with the standard operation that a risk-benefit analysis changes the needed operation to one requiring an EVAR graft. These are provided. When a patient “prefers” a graft over an open procedure he/she should have no expectation that you or I or any other public member should be obligated to pay for that preference. This is the key issue under debate at the moment.
If one has $15,000 in a public system one can provide the needed operation to 10 individuals or the “preferred” operation to one individual. When an individual argues on the basis of preference, that person effectively steals operations from others who need it. Wise use of healthcare resources in a clearly rationed situation of public expenditure for public good requires a careful examination when expensive procedures jeopardize care to others on the basis of bankruptcy. Health Authorities cannot borrow money. You describe the process as “ridiculous”. The process is not ridiculous at all. What is ridiculous is when an individual expects to demand an expensive preference over an available alternative at the expense of others who also need a procedure. EVAR grafts are available for those who truly need them. For those who want them as preference we need to develop a means by which those individuals can pay the difference and not obligate the public.

Anonymous said...

"And, the surgeons said, the costs are the same if you include the extra time in acute care beds required by patients who undergo the traditional surgery. As well as being better for high-risk patients, the stent procedure means about a week less in hospital, so the real costs are in the same range."

Healthnutdoc makes some reasonable points, but his lengthy scold fails to square the circle of "ridiculousness" (is that a word?)in cases just such as Paul's column actually referred to. Supposing the surgeons' quotes to be reasonably accurate, how would it be an impertenance to "prefer" the least invasive of the two procedures?