Tuesday, February 02, 2010

Tough decisions on rationing health care

A Vancouver Province news story last month indirectly raised one of those health care issues no one wants to talk about.

Cutbacks would mean 2,450 fewer surgeries in the Lower Mainland, the article said. The excuse was the Olympics, but really it's a cost-cutting measure. (Otherwise, the lost surgeries could have been made up during the rest of the year.)

The reporter found people to put a human face to the story.

One woman said she urgently needed a new hip. "I'm in pain, but the medications they give me for pain make me sick," she told the reporter. "I'm confined to a wheelchair when all I need is hip replacement surgery."

She hasn't even been given a possible date for surgery because of the "Olympic slowdown."

Here's what stopped me. She was also 91.

Health care remains affordable; governments have just been reluctant to allocate the needed money, judging lower taxes a bigger priority. With good management and system reform, it will remain affordable. (Though we're lagging on both counts.)

But rationing care is part of the reality in the near term, longer if we don't improve efficiency.

And the notion of a hip replacement for a 91-year-old raises questions about just how we're going to decide who gets care.

Right now, it's informal. Specialists and committees make judgments about who should be treated first based on urgency and other factors.

Some people are constantly bumped down the list. It's tough to have confidence in fairness. (And of course, people with money pay for private care - supposedly illegal - to avoid rationing.)

We need to talk about the process honestly, to improve fairness and cost-effectiveness and to allow informed decisions about the current level of rationing.

The issue is sensitive. But better to discuss the criteria for rationing than to allow it to happen without any public input or assessment.

It doesn't need to be - shouldn't be - entirely arbitrary, based on age, for example.

But take a person of 91 in the queue for a hip replacement. A new hip can last 25 years. So spending the money on a 40-year-old buys many more years of benefit. The risks of complications or an unsuccessful outcome also rise sharply, according to recent studies.

Ideally, we decide both deserve timely surgery so they don't suffer and live shrunken lives.

But if that won't happen, we should be upfront about how and why the decision was made.

The discussion alarms people. For instance, should people who are seriously overweight have the same access to knee and hip replacements?

It's not a moral judgment. The surgery is riskier, outcomes poorer and the artificial joints don't last as long. A few years ago, some British National Health managers faced a budget crunch and quit doing knee and hip replacements for anyone with a Body Mass Index over 30. If you were five feet nine inches tall and weighed 205 pounds, no new hip until you lost weight. (Some doctors in B.C. take the same approach, but the system doesn't.)

The British National Institute for Health and Clinical Excellence looked at one of the most controversial rationing questions. What if the patient's illness is self-inflicted?

Should a child who needs a liver transplant wait in line behind someone whose illness is caused by years of alcohol abuse? After all, addiction is a disease.

The institute decided that what mattered was not past behaviour, but future prospects. A child with a new liver thrives; an alcoholic, statistically, is at high risk of returning to drinking.

This all started with the 91-year-old waiting for a hip transplant. But there are two issues. When do we want to say no treatment for you. It's not worth the money.

And how will make those decisions.

Right now, we pretend they aren't being made. That's cowardly, and it's keeping us from a serious health care discussion.

Footnote: Here's one of the most interesting numbers. Of all the health care costs you occur in your life, 35 per cent will typically come in the last six months. And then you'll die. Beyond efforts to improve your comfort, it hardly seems smart spending.


Paul Ramsey said...

If only we knew exactly when people were going to die, we could make some smart decisions in those last six months, hey?

paul said...

We often do. I read a couple of last-six-month studies for a column several years ago and very old, sick patients went through extraordinarily aggressive, expensive and futile treatments. (Partly, the system provides incentives that encourage that, especially in the U.S.) One study found 40 per cent of terminal cancer patients had received chemo in their last month, even though there was no clear palliative benefit.

StandUpforBC said...

Paul, thanks for speaking truth about our current health care system. Your column is wise, and most importantly, tinged with compassion.

Our health care system is run not so much by bureaucrats, but by doctors -- doctors who don't have the training or the incentives (personal or systemic) to render good judgement. A fundamental problem is that doctors are trained to treat a person, not a population. So, it's no wonder the health care "system" is so badly off-course.

Lest anyone think I'm damning all doctors, I highly recommend that anyone even remotely interested in health care in BC read:

"A Bitter Pill - how the medical system is failing the elderly" by John Sloan, MD .

This book is an enormously readable, first-person (doctor) account of the folly that is modern medicine when applied to frail elderly people, and how it is actually very detrimental to their health and well-being, and how our health care resources are squandered on foolish, impractical and cruel practices within the medical "system", with dire consequences resulting for all ages.

A Bitter Pill should be mandatory reading for every bureaucrat and politician in BC, and for that matter, Canada, and mandatory reading in all medical schools. The book describes exactly what you wrote about Paul, and more. Dr. Sloan shows why such foolish practices occur, and what the effects are. And, he also provides practical insight into how we could make massive improvements in the health and quality of life of seniors, AND reduce or redeploy our expenditures on health care services.

Dr. Sloan is a Vancouver family doctor who has 30 years experience providing medical care to the elderly. His book was published in December 2009 by Greystone Books, www.greystonebooks.com . Individual bookstores (esp. local) can order it for you. Munro's in Victoria was sold out a week after the book came out, but they ordered a copy for me and it arrived a few days later.

Paul, you said we need to talk about the process of health care rationing honestly. I suggest it's time to talk about the entire delivery of health care honestly, and I suggest this book is the best place to start.

As an adult child of a beloved elderly mother, I can attest to many of the follies that Dr. Sloan describes in his book. He is a brave man with a refreshing attitude and a charming manner. Oh, if only we could have more like him in BC!

DPL said...

But Paul we all know folks who are in poor physical shape at 30 or 40 and some who are in very good shape at 90. Just go to a rec center such as the Esquimalt Center and see the older group cleaning the next younger group, in the pool. My better half is in a womans walking group where 70 is about the youngest and they range up to over 90. One hopes when your wife gets old she isn't denied medical care when needed. Hip replacement costs have come down considerably and the results can be spectacular. The surgeons have to have the wisdom of God as they shift their wait time lists up and down. we cn't use the old, put em on an ice flow method anymore so they either get fixed or spend a lot of time in a hospital waiting to die, eventually

off-the-radar said...

Gee Paul, elderly people deserve full health care too. It's not like you hit 90 and you're cut off from health services.

End of life care probably warrants further discussion.

Also poverty is a huge negative factor for health outcomes. Those people in the bottom income quintile have much worse health (diabetes, heart disease etc etc) than those in the top quintile. Improving income and supports for those living in poverty (including 1/4 of BC's kids) would improve health for these citizens (and reduce health costs).

Anonymous said...

Paul, you have put your finger on one of the glaring problems with our health care system - that so much is spent on people in what proves to be their last six months of life - but "off-the-radar" touched on another one that's just as important: preventive health care and education, especially for lower income groups, yields both enormous benefits to the person and greater savings down the road for society. Our health care system is one that's geared towards fixing acute problems and responding to crises - very, very little of the MOH budget goes to preventive services. For example, I believe (correct me if I'm wrong) that regular checkups with a family physician (and the supply of those is a whole issue by itself) are not paid for by MSP.

Anyway, yes, these are the discussions no one wants to have but they should take place, for the sake of us all.

Andrew Chisholm said...

Here is the last part of an article from the
Canadian Health Services Research Foundation
Myth:The cost of dying is an increasing
strain on the healthcare system

Research can’t do everything
Clearly, research has debunked the myth that the
cost of dying is growing and overwhelming the
healthcare system. The question that research will
never answer, however, is whether that spending
is too high — that’s a question of values, which
number-crunching will never answer.
Even if society does decide that spending at the end of life is too high, it is unclear what could be done about it. Research has shown some likelihood of reducing costs with increased use of hospice and
advance directives,ii but there are other critical and
possibly disturbing policy implications that will
emerge as people try to decide how aggressive
medical care at the end of life should be and
how costs can be reduced.
In the end, it is difficult to predict which patients
receiving treatment will live and which will die
(with the exception of some forms of terminal
cancer). In other words, care in the last year of life
is not so much “spending on the dying” as it is just
providing regular medical care for people who have
serious health problems.

services prior to death: a comparison of the Medicare-only
and the Medicare-Medicaid elderly populations.

Mythbusters are prepared by Knowledge Transfer staff at the Canadian Health Services Research Foundation and published only after review by researcher experts on the topic.
© CHSRF 2003