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Wednesday, August 19, 2015

Health care rationing: the roar and the silence

I have gotten the impression over my years in medicine that essentially no one likes to talk about rationing care. Those who oppose the concept on ideological grounds certainly don't want to talk about it. Those who are in acute need of care for themselves or someone they love are potential “victims,” and especially don't want to talk about it. Policy makers who may want to talk about it have learned not to like doing so, because no one seems to like hearing what they have to say.

Despite that, the relentless imposition of a simple fact, resources are never infinite, has resulted in some experimentation. Notably, the state of Oregon initiated a program in the mid 1990s that was called health care rationing by most observers. Defenders were prone to say it never really rationed health care, but rather was a system for “prioritizing funding for health care through systematic and public ranking of medical services.” But add finite resources to that characterization, and run it through a universal translator, and “rationing” pops out. By whatever name, the experiment in Oregon lost support over time, and eventually, came undone. To my knowledge, there has been nothing like it in the U.S. since.

That is not to say rationing has become irrelevant. Quite the contrary, health care economists, medical philosophers, and policy makers across the political spectrum, have suggested that we ration health care resources routinely in the U.S.

There is an unavoidable consequence of doing something you aren't willing to talk about doing: you do it badly. No discussion means no probing, no deep thinking, no careful exchange of ideas. We do, indeed, ration health care in the United States; we just don't talk about it, with the result that we ration it altogether irrationally.

What do I mean? There is almost no limit to what we will, and routinely do, spend on the often desperately futile care at the very end of life in very elderly people with multi-organ-system failure, a long history of serious chronic disease, and virtually no chance of getting back to a quality of life any of us would be willing to accept. But we routinely fail to cover the costs of effective preventive services that can save both lives and money, and impose substantial barriers in the form of co-pays and deductibles on care that is essential. One could argue that rationing of dollars is even more extreme in the research context, where we spend a lot on treatment advances and near-to-nothing on prevention; lavishly on learning what we don't know, and negligibly on putting what we do know to good use.

At the peak of attention to health care models, before the Affordable Care Act came off its assembly line, colleagues and I published a proposal for a tiered model. We suggested that certain varieties of care, both effective preventive services, and urgently needed treatments, should be available to all with no financial barriers. A tier of services of slightly lesser value or need could be available to all, but might reasonably involve some barriers in the form of copays. Finally, a tier of quite discretionary services might come entirely out of our own pockets. This is one example of potentially rational rationing.

But as noted, we don't like to talk about rationing. So we just keep doing it badly.

As some of you likely know, I have for several weeks now been championing the case of a 23-year-old college student with the dreadful, dual burdens of a rare, life-threatening cancer; and an insurer refusing to cover the costs of care recommended by his oncologist. I write today partly to announce that the Change.org petition I started on behalf of Manny Alvarez and his family, directed at getting Blue Cross Blue Shield of Florida to reverse its denial of coverage, has over 100,000 signatures. That is a roar.

But I am puzzled by the silence. We are, after all, a population of some 3 million here in Connecticut, so 100,000 is just over 3% of us. We are, in the U.S., some 300 million; so 100,000 is just 0.03% of us. That's a lot of silence.

Of course, we can trim those silent majorities from 97% and 99.97%, respectively, by eliminating all who are too young, too old, have no Internet access, don't speak English, or just never got the memo. Still, there's a lot of silence left.

There are many reasons for it, but I am quite confident that agreement with Blue Cross Blue Shield of Florida is not on the list. If anyone, anywhere believes that the right time to ration care is when a formerly healthy, vibrant 23-year-old has his one best shot at surviving by use of care chosen and recommended by an expert oncologist, I've never met them. I am quite sure they don't exist, outside of insurance companies.

Frankly, I would like less silence, so if you have not yet shouted your signature on Manny's behalf, I ask that you do. Please chip in and help the family directly while you are at it, if you can. But either way, Blue Cross Blue Shield of Florida should know that agreement with their decision is not among the explanations for your silence. In contrast, impassioned disagreement is exactly the reason for the roar of over 100,000 who stand with Manny Alvarez.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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