Friday, March 20, 2009

Rationing of Care...

Good article in the times....

NY Times

Blue Cross and Blue Shield of Massachusetts, the state’s largest insurer, recently devised an innovative model that pays doctors a flat fee per patient, with adjustments for age, gender and health status, and then adds bonus payments for high standards of care.

Blue Cross officials say they believe that the new plans can cut the growth of premiums in half over five years and expect them to account for 15 percent of their business by June. “We’re very committed to this path because we feel it’s the only credible place to go,” said Cleve L. Killingsworth, the company’s chairman.

Some health policy experts argue that changes in payment practices will not be enough to slow the growth in spending, even when combined with other cost-cutting strategies. To truly change course, they say, the state and federal governments may need to place actual limits on health spending, which could lead to rationing of care.

“Really controlling costs requires just stopping spending,” said Stuart H. Altman, a professor of health policy at Brandeis University.

Because Massachusetts now requires its residents to be insured, it cannot fall back on the strategy used by other states in hard times — to simply remove people from the public insurance rolls by restricting eligibility.

“It forces us to look in the mirror and say, ‘What do we do about health care spending?’ ” said Jon M. Kingsdale, executive director of the agency that administers Commonwealth Care. “And the reason that’s so challenging is that it means limiting resources for people doing really good stuff.

“It’s not like the fat sits out here easily identified and you just slice it off. It’s marbled throughout the meat.”

This is going to be more problematic than I think they realize. It will almost certainly lead to rationing of care, just like the flat fee HMO payments did, and this was noted on Whitecoats Call Room blog as well.

Many are concerned about this, problem is...Rationing already occurs to a large part. Right now, we ration care by insurance status. Patients without insurance, or without good insurance, cannot obtain appointments, and cannot get adequate care.

Rationing is inevitable. Look at it this way. There are two factors here.

1. There is a finite amount of money available to pay for care. Despite you having insurance, there is still only so much money in the pool.

2. There is a limit to the amount of resources, or care available.

NOW, in order to provide unlimited care to everyone, you need to have an unlimited pool of money, which we do not have. Therefore, one pool, or the other needs to be managed, or rationed effectively.

It is simply reality. My question, is how should we ration care?

My opinion is to really ration care in the last six months of life, and amongst the elderly. Greater utilization of hospice for end stage patients. Decreased use of multiple medications and procedures that cost a lot, but have little if any proven benefit.

For example, in the UK, if you are 80 years old, and develop renal failure. You don't get dialysis. Not usually. They have decided that at the age of 80, the amount of return that their society will get, measured against the massive costs, are not worth the investment. How would that go over here?


. said...

I think that's terrible, just awful. Since when does being 80 mean you deserve less care, simply because the 'payback' isn't enough of a kick?? What kind of a world do we live in where we 'cut costs' at the expense of a life? I don't care what the age of an individual is. If they're not given proper care, it's slow murder and nothing else.

physasst said...

How do you propose funding and providing care for everyone with limited resources? If there is a way to do it, I am all for it. Otherwise, we need to realize as a society, that we are spending MASSIVE amounts of money with little benefit. A large percentage of all the money spent on a persons healthcare occurs in the final two years of life. We need to recognize this, and perhaps say, do we need to do this? It's not a popular concept, yet we wonder why medical expenses are far outpacing GDP, and why Medicare costs are increasing exponentially. These are the sorts of difficult, and not friendly discussions that we unfortunately NEED to have.

grindcm said...

The cost of health care has been a constant issue for quite some time and the solution to the issue has eluded us, which I would beg to differ. Because of the market mentality of health care the solution must decrease expense while maximizing revenue and this is the area that produces the issues, money. I believe that we could attribute the grand expense of health care to one facet of health care reimbursement, insurance companies. Needless to say, I can and will say that much can be said about the topic and little can be done from a consumer stand point