the ted kennedy affordable health choices post

From CNN.com:

Surgery is usually followed by six weeks of radiation. Kennedy wrote in a Newsweek magazine article that he underwent proton-beam therapy, a type of radiation therapy, at Massachusetts General Hospital.

The hospital is one of only six centers in the United States that offers proton radiotherapy, according to the nonprofit National Association for Proton Therapy.
...
The average life expectancy is from 15 to 18 months after surgery, Morrison said. Only about 10 percent of patients are still alive after five years, Junck said.

This treatment would have been very expensive.  If it's only available at six facilities nationwide, then you know it's scarce.  And if that's what Ted Kennedy got, then you can bet that some expert somewhere believes it's the best there is.  Hell, they probably even debated whether any of those six facilities was better than the others; Kennedy didn't just get the best -- he would have gotten the best of the best.

And as good as that may be, more than half of the patients are dead within a year and a half, and all but 10% are dead within five years.  This is a very poor prognosis.

In fact, the prognosis was never even that good for Ted Kennedy -- he was 77 years old.  Even if his cancer had been cured, there's still a litany of things that might have killed him within five years.  Even if Kennedy had licked this cancer, he was very likely to have developed another one, or to succumb to a heart attack, stroke or some other "natural cause" within the next few years.  This was never anything but a long shot.

In other words, the money spent on Ted Kennedy's last couple of months was wasted.  This therapy was, in a word, "unnecessary."

Now I want to ask:  If it happened to you -- and if you were insured under The Ted Kennedy Affordable Health Choices Act -- do you think you'd have gotten the treatment?

Because when Obama and Ezekiel Emanuel talk about eliminating "unnecessary" and "ineffective" procedures -- these heroic measures are precisely what they're talking about. 

Some commission, which I think we can safely say would not be called a Death Panel, and which for some strange reason would include "bioethicists," would determine in advance that most (probably all) patients would not benefit from this procedure, and so it would not be given.  Certainly not to 77-year-olds.  It's expensive as hell, and we could give a lot of preventive care to the homeless with that same money.  Or to some younger, more productive taxpayer who isn't a drain on Social Security.  Instead, you would receive a pill.  And no doubt some very thoughtful, compassionate, and even helpful counseling about facing the end of your life.

But today, you have a crack at that care.  You might receive that treatment through your insurance -- even if the odds would be stacked against you.  If you had to, you could mortgage your house to pay for it.  It might even be covered by Medicare. 

The downside of you having that chance -- that "luxury" --  is that some person who's poorer than you; someone who doesn't have a house to mortgage -- just as you are poorer than a Kennedy -- he doesn't get that chance.

Notice that the solution our politicians have come up with is to put you and that poorer person on "a level playing field" -- a field where that option doesn't exist at all.  A playing field that's level enough for you and, say, some homeless person -- but perhaps a little too level for a Senator.

Or better yet, imagine if the homeless guy gets the procedure at your expense -- but you can't get it because you're too old.  It would be funny if it wasn't really happening.

I find it interesting that it will always be okay for a Kennedy to have access to care that you can't have, but for some reason it's immoral for you to have access to care that a poorer person can't get.  When it's the difference between a Kennedy and you, that's "Camelot."  But when it's the difference between you and someone else it's "an injustice."

I thought the reason you always worked so hard was so that very precious things would be within your reach when you needed them.  Apparently you're not as precious as you thought.  Not as precious as a Kennedy, huh?

Comments

[Jim]

How can we make people think? Why is it that to most people, the idea of being a peasant is ludicrous, but when they are treated as such daily they accept it without protest?

Just waiting on the revolution friend, just waiting on the revolution.

[ConservativeLibertine]

"Some are more equal than others"

Ted will be remembered as a "fighter". He got to fight to the end precisely because of the reasons you espouse.

When the time comes, the rest of us will be 'counseled' not to waste vast resources, and to end our fight for the benefit of the collective.

"Some are more equal than others"

Ted was a Napoleon

http://en.wikipedia.org/wiki/Napoleon_%28Animal_Farm%29

We are like Boxer

http://en.wikipedia.org/wiki/Boxer_%28Animal_Farm%29

We will end up at the glue factory.

[Hal Horvath]

A couple of months ago, on my first post in which I thought about Health Care Reform I came up with one initial idea that one way to balance finite resources against this reality that we *already are paying* (all of us that pay taxes and insurance premiums) for free Emergency Room care for poor people was...

was to establish, as you yourself suggest, "merely good" care as a basic standard, and then allow the private free market to continue to sell, just exactly as it does right now in relation to Medicare for older people, supplemental insurance, where anyone can buy better care, above that basic standard.

http://findingourdream.blogspot.com/2009/06/good-healthcare-ideas-help-think-up-new.html

But more, I proposed this "basic" care be limited to cost-effective treatments ("merely good" is your own term I believe) so that *most lower-income people could in fact actually pay for it themselves*!

Without subsidy.

So that the subsidy for the remaining very poorest would not amount to some huge number like $100bn/year, $1 trillion over 10 years, etc., but would be much smaller, perhaps 1/2 that size or less.

So...that's a better solution I think than many ideas in Congress...

But...it's not the best idea I finally settled on myself for the best reform.

For an even better idea, more free-market based, look here:

http://findingourdream.blogspot.com/2009/06/new-way-to-hold-down-health-care-costs.html

But, all of this said, if you talk about "necessary" and "unecessary" and who decides, etc., etc., in terms of what Congress itself is currently proposing in the 5 bills that passed committee, that's a separate question.

I'm not in Congress, and didn't write those bills, but...also I'm not currently aware of them specifying that treatment reimbursements be age-dependent.

Instead, the clear meaning of "unecessary" to my understanding in current Congressional proposals is to refer to redundant tests (duplicates), and such things as hospital re-admissions because doctors at a particular hospital refuse to wash their hands (this is one bit in a recent Atlantic article I believe.)

I went further than only such questions. I considered the inevitable grey areas, which exist under each and every possible public or private scenario. That's were my own proposal (2nd link above) helps.

Still, ultimately, reality is that anyone wanting the most rarified, expensive, new-technology care *should* pay for it themselves -- privately pay those supplemental insurance premiums themselves.

So, there isn't such a huge flaw in the proposals, so far as I understand them, in the particular regard of choosing who lives top-down, from above.

Any public standard indeed brings this issue to play, and before the public standard, the issue was already in play, but privately. Already, decisions are made, by hospitals and insurers, for many patients, top-down.

Perhaps the best argument for some reform of this type -- "merely good" universal care -- is that it can help in two ways -- a) preventing the worst situation of people dying from lack of very basic, relatively cheap treatments, and perhaps b) some actual cost-savings over time for taxpayers and policy-holders when the currently subsidized Emergency-Room care is less used -- paying for diabetic care before amputation, as Obama says, etc.

There is no easy solution. But my 2nd link above is the best idea I've found or seen so far.

[John Galt]

Insurance companies already ensure that procedures are medically necessary and efficient. They don't authorize care that won't work, but they must authorize care that might work -- or they must be prepared to defend the denial in court. They have enormous incentives to minimize the cost of each patient's care.

The only substantive cuts left to be made are cuts in care -- cuts based on statistics. Not based on the certainty that a procedure won't help, but rather on the probability that it won't. Cuts beyond what an insurance company could get away with. Cuts that require "tough choices." Cuts that require bioethicists -- rationing experts.

It is nothing short of intellectual dishonesty to pretend that significant savings will be found through any other route. You yourself, Hal, have admitted that slightly-less-good care is the key. And Obama's cuts will target the excellent to maximize the good. That is why his experts are bioethicists -- experts at rationing -- and not experts at caregiving. They are people who specialize in finding reasonable ways to make "tough choices."

I'm happy to discuss increasing accessibility through judicious cuts in quality. But don't insult my intelligence by pretending that the system is overloaded with "unnecessary" care. The insurance companies already take care of that. It's necessary for someone -- just not anybody the government values enough to pay for. That's Obama's real definition of "unnecessary" -- the terminal patient.

[Hal Horvath]

Regarding "cuts to target the excellent to maximize the good" [first, I don't expect you imply a plan is afoot to allocate certain treatments by lottery or age or some such -- that would be quite radical, but I haven't seen or heard of any such specific radical proposals of any sort...] -- if you are saying there is an intent to prohibit or tax some expensive therapies, I just haven't seen such language. You'll have to show me a specific proposal in an actual bill in question. I have heard discussion to the effect that individuals would continue to be free to buy supplemental private insurance, which seems a certainty in all scenarios.

I won't presume something like that without specifics -- the language in a bill.

As far as the idea of 'wasted' care (a common term used widely), that isn't my idea or Obama's but rather the results of research at universities I understand. I don't have a link -- I haven't specifically reviewed this research. Of course, there is research in physics I haven't reviewed, etc., yet I don't doubt that research because I haven't seen it. The odds are quite strong the medical-outcomes research is not profoundly wrong, as that kind of thing would draw scrutiny, due to its importance. For instance, if a scientist claims to achieve cold-fusion success, it would get a lot of scrutiny, due to its importance, etc...

Instead of asserting such research must be wrong, the burden of proof is on the person seeking to challenge it, if there is any reason to do so. He or she would need to review statistical data, etc., and do comparative analysis.

We do know we spend much more per person than European nations that achieve population health outcomes as good or better than our own.

That fact suggests something of some sort is indeed different. It's a fact we have more technology and tests. Is that most of the difference? Data is the answer to this question, not logic.

We don't have longer life expectancy than these nations that spend less.

But...we don't even have longer life expectancy for those that turn age 60! (so it's not about the number that die young, etc.)

In terms of life-experience, waste seems plausible. I have seen even dealer auto mechanics, for example, do many ineffective repairs on a troubled car I owned, which remained troubled after more than $2000 of work, only to be quickly and easily fixed by another mechanic elsewhere for about $190. It's ran perfectly since.

I don't need to have proof to know some doctors are considerably more competent and able than others.

This is normal in every field of endeavor.

It stands to reason then that the competent doctors will often deal with certain conditions far more effectively and thus reach a certain level of successful outcome with *less* treatment and thus less total cost than a doctor who first wastes time and money with a less effective treatment.

We know that most medical spending is on the sickest patients, a small group. The pieces fit together -- competence in the doctor could result in a large cost difference in a patient that has a complex condition.

That's not at all hard to imagine. It certainly happens plenty. In fact, talk to anyone with a difficult condition, who had to go to more than one doctor to get an effective result. The only question is how of this incompetent care is there altogether?

One huge advantage Mayo Clinic has (the nation's top hospital) is exactly that care is team-care, so that expertise is pooled.

Could it be as much as 30% of all care in the U.S. is wasted (the wrong treatment first, before a better one, where a better doctors wouldn't make that mistake)? Sure. It could be. It could be 15% or 40%. It could be a lot of numbers. Not hard to imagine at all.

So, rationally, the exact size of that number is a matter of precise research and concrete information, not of theory. Scientific method. Not logic alone, but rather data primarily.

In other words we certainly cannot establish whether there is 30% or so waste in medical care here in this forum via logic alone. We'd need research data instead.

[Hal Horvath]

Here's a brief overview I just saw of the current health care situation, for those that dislike lengthy analysis and detail.

http://www.thehealthcareblog.com/the_health_care_blog/2009/08/health-care-reforms-deeper-problems.html

[John Galt]

Hal:
"first, I don't expect you imply a plan is afoot to allocate certain treatments by lottery or age or some such -- that would be quite radical, but I haven't seen or heard of any such specific radical proposals of any sort..."

Yes, I am implying that. Read up on "The Complete Lives System," a care rationing model espoused by Ezekiel Emanuel.

"You'll have to show me a specific proposal in an actual bill in question."

Regulation doesn't work that way. You create a provision to establish a regulatory body, and then you populate that panel with people who hold whatever philosophy you want. Philosophies like "The Complete Lives System."

"We do know we spend much more per person than European nations..."

We also spend much more for education outcomes that are largely worse than everyone else. How do you reconcile that? Both systems' declines can be traced to increasing government involvement. Government is not the healthcare solution -- it is the healthcare problem.

"...that achieve population health outcomes as good or better than our own."

Highly subjective. Highly doubtful. The sources of claims like that also claim that Cuba's healthcare is pretty much on par with our own. In fact my definition of "idiot" is someone who can't decide whether he'd rather have American care or Cuban care because the rankings are so similar. Rankings mean nothing, because so many of the data points have nothing to do with quality of care. Nobody who's actually sick would choose Cuba for critical care. It's not even close -- what makes you think the statistics you're using are any better? For all I know they're the same ones.

"I have seen even dealer auto mechanics, for example, do many ineffective repairs on a troubled car I owned, which remained troubled after more than $2000 of work, only to be quickly and easily fixed by another mechanic elsewhere for about $190. It's ran perfectly since."

That doesn't mean the $190 problem was the most likely cause. Or any easier to diagnose. Or that the $2000 repair wasn't necessary, or that it wasn't worth it. Or that the $190 mechanic didn't know the $2000 repair had already been tried. Or that the $2000 mechanic was trying to rip you off, or incompetent. Plus, if the $2000 diagnosis fixes the problem 99.9% of the time, do you really think Obamacare is going to test everybody for the $190 condition???

"I don't need to have proof to know some doctors are considerably more competent and able than others. This is normal in every field of endeavor."

And that is why the proposed solution includes incrementally replacing doctors with a greater number of less competent ones. Perfectly logical if you're honest about it. But not "just as good," as the President suggests.

"It stands to reason then that the competent doctors will often deal with certain conditions far more effectively and thus reach a certain level of successful outcome with *less* treatment and thus less total cost than a doctor who first wastes time and money with a less effective treatment."

Not true. These are professionals applying standardized approved procedures according to standardized approved protocols, all of which is authorized by third-party payers with the means and motive to prescribe the most cost effective treatment.

"We know that most medical spending is on the sickest patients, a small group. The pieces fit together -- competence in the doctor could result in a large cost difference in a patient that has a complex condition."

This isn't about better care. It's about less care where care promises to do less good. Where the prognosis is poor, where the patient has fewer productive years left. That's what The Complete Lives System is.

Most of the rest of your comment is just good-ole-fashioned Kool-Aid drinking. Don't forget to wipe your chin.

[Hal Horvath]

"I have seen even dealer auto mechanics, for example, do many ineffective repairs on a troubled car I owned, which remained troubled after more than $2000 of work, only to be quickly and easily fixed by another mechanic elsewhere for about $190. It's ran perfectly since."

That doesn't mean the $190 problem was the most likely cause.

??

??

That's quite a reach.

The competent mechanic simply figured out the problem from the symptoms. The incompetent one tried whatever he could think of, which wasn't the actual cause of the symptoms -- a faulty knock sensor. Was 100% of the $2000 wasted? No, but...it did not fix the trouble.

This is interesting: one thing the $2000 included was a 60,000 mile tuneup, for which the car was early, having been only about 50,000 since the last... and the charge was about $800.

But at the competent mechanics shop, that same tuneup was listed at $660.

I found that interesting.

That's similar to how the Mayo Clinic both has better results and is higher rated (see a recent report of your own choice), yet has lower costs.

There is such as thing as competence.

Read Atlas Shrugged, or other works by Rand to see some illustrations, or talk to people, or recall events in your own life, if you are over 35.

[John Galt]

You're being silly. I merely responded to generalizations by pointing out all the unsupported conclusions you were drawing. If the actual specifics are supposed to be significant, then you should have included them in the original comment. You get no high ground for having asymmetrical information that you didn't present as part of your original example.

Sometimes an automotive problem boils down to a couple of pennies worth of wire that's broken or shorted in just the right place. You could spend thousands of dollars fixing all sorts of things before somebody figures it out. That doesn't mean the first person who worked on it is incompetent, or that the guy who finally figures it out -- with the benefit of the knowledge of the work the first guy's already done, mind you -- is any better.

What matters here is whether a warranty company, with its own expertise on staff, would have authorized the original, incorrect repair. You may be on your own when you go to a repair shop, but you bring a knowledgeable partner -- your insurance company -- when you visit your doctor. Once again you fail to account for how all this waste funnels through the player with the biggest, most obvious interest in reducing it.

Why do insurance companies authorize "unnecessary" procedures? It always comes down to this. And you never answer it. Why, I wonder?

The answer is because insurance companies (who can be sued by patients) deal with a different definition of "necessity" than you might find in "The Complete Lives System."

Do you even realize you are party to a swindle?

[Hal Horvath]

It's a good argument, though I think you are missing information (actual research data/articles) on so-called 'wasted' care. (To find such research, google 'wasted health care' or other such search terms)

The argument itself is logically sound given the set of information I think you have.

But, this is an interesting question:

"Why do insurance companies authorize "unnecessary" procedures? It always comes down to this...."

I can't speak for all insurers (or even for any!), but...I think in general, with exceptions, usually insurers are *not* competent to know whether the doctor is making the best choice in most situations, especially in PPO policies (which are commonplace). And the insurer knows this. Therefore, all the insurer can do, for those PPO policies (which are not the "managed care" HMO policies)...is try to detect when there is an incompetent doctor and cancel their contract with that one doctor (remove him/her from 'in-network' status).

So it's information-asymmetry.

So, I'd agree with your conclusion *if* I restricted my information to exclude research on medical 'waste', etc.

While it's possible to simply conclude the wide array of 'experts' who 'agree' there is significant (instead of little) medical waste are correct, one can indeed challenge this idea, but only by spending the hours reading research in journals and looking over actual data (not just arguments alone). To do such checking competently, I'd need to search out the best articles, and on both sides, if there is more than one side, and also look over data sets at least some, and also compare such data sets to those in other research articles.

[John Galt]

So it could be that "waste" is what I describe, or that "waste" is what you describe.

And yet, bioethicists like Ezekiel Emanuel are people who specialize in the kind of waste I describe. When Obama refers to "tough decisions" he's referring to my definition of waste. How does your version of "waste" involve any "tough decisions"?

What is The Complete Lives System if not a guide to making "tough decisions" about rationing care? That's exactly what it is. It's what Emanuel specializes in.

You're in denial. Go be in denial elsewhere.

[Hal Horvath]

Ok, but to avoid being in denial yourself, you'd have to investigate the research and data on 'waste' that in fact is available on the internet from research journals for yourself. That's strictly up to you.

[John Galt]

No, not really. Only one of us is in denial. I'm sure there are all sorts of actual inefficiencies. Medicine is an art, and there are few "textbook" cases of anything. But these inefficiencies won't get any better under government control -- they'll get worse. Medicare is already subject to much more fraud than private insurance. Nothing beats the profit motive for controlling waste, because somebody actually gets a commission for fixing it. No other model has that.

And those real inefficiencies don't matter -- what matters is that Obama does intend to take over the "tough decisions." Inefficiencies that aren't inefficiencies. They're going to eliminate waste that isn't really waste at all, but simply compassion. They want to stop wasting care on people who will almost certainly die, and put those resources to work on someone who's currently uninsured.

And the funny thing is that I'm far more concerned about the rampant intellectual dishonesty on this issue -- such as you've demonstrated -- than I am with the reality of rationing. We already ration.