Peculiarities of Class

Nearly 20 years ago I had a young man present with a fractured a rib from a fall. I noted aloud the codeine allergy "documented" in his chart when I had first seen him 3+ years prior. I've never forgotten his response.

"Doc, I'm not allergic to codeine. I used to say that when I was still doing drugs so I could get Vicoden instead. We'd take 6 or 8 Vicoden at a time to get high, when I tried that with codeine, I'd just throw it up".

Drugs within the same class may (or may not) have significant differences in side effects (as above), intended pharmacologic effects(ditto) and cost. These differences are exploited by every player in the medical care bazaar.

My patient exploited differing intended and unintended side effects of two narcotics.

Drug reps exploit the most miniscule distinction to try to sell me on a product while talking down price disparity.

Insurance companies force choices due to cost while ignoring other considerations, regarding generic (same chemical) and same class (similar chemicals) as synonyms.

Recently I had a patient's spouse who explicitly adopted the latter view and was angry when I tried to explain the distinctions between one of his meds and her proposed substitute. "They're the same, there's no difference, they're in the same class".

The medicrats are smiling.

Ezekiel Emanuel and Medical Rationing- Link

Ezekiel Emanuel (Rahm Emanuel's brother) is an influential player in health care reform and rationing. I began to write posts descibing his writings, but I didn't complete the pieces, yearning for someone more erudite to do so.

DrRich (the must-read writer on medical rationing) has now published a must-read article on Emanuel here.

Will The ObamaCare Plan Lead to Rationing?

Current public debate over the Obama/Congress health care insurance reform bill(s) has been increasingly fixated on whether or not health care "rationing" would result.

What is medical/healthcare rationing?

"To ration healthcare is to withhold at least some useful medical services from at least some of the people who would benefit from them." (per DrRich at covertrationingblog.com)

Does the Obama administration's plan include rationing?

Actually, we already have rationing, but it's not usually recognized.

Medical rationing comes in two flavors, covert and open/explicit.

Covert rationing occurs every day, as doctors and hospitals jump through the hoops required by government and insurances to treat people. The various delays, frequent rule changes, preauthorizations, unexplained denials & etc. are rationing methods covertly practiced on thousands of patients every hour. These techniques are designed to manipulate doctors and patients to change diagnosis and treatment plans for the benefit of the insurance company or government budget. Much of the disgust with insurance companies derives from these practices.

Covert rationing is both ineffective and destructive of the relationship people have with doctors. The additional medicrats required eat up any savings. Doctors become seen as a hurdle between the patient and some desired end. I have had many patients leave my practice angry at me when I have been unable to convince a stonewalling insurance company to pay for something. HMOs are a special type of covert rationing where the doctor performs rationing on behalf of the insurer and for the benefit of him/herself.

Open rationing occurs when an explicit decision is made to not cover a useful medical service ( e.g. no dialysis past age X) and is considered by many Americans to be distasteful, even evil. I practice in a state whose Medicaid system developed a controversial explicit rationing system in order save enough money to cover tens of thousands more people. It worked fairly well until the Federal medicrats put the screws to it. Open rationing is a common bogeyman in American politics.

The Congressional plans have no explicit language establishing open rationing. That means that covert rationing will be the main method of attempting to control costs in the system initially, and it will continue to be both ineffective and destructive. As long as people can make someone else pay for their medical care, no one will be able to quench the unceasing appetite of Americans for all possible care, all the time, immediately, for every ailment and symptom (The Happy Hospitalist often states: FREE= MORE MORE=BANKRUPT).

That is a huge flaw in the Obama plan. It can not control the costs because it cannot control the volume (this is a major problem with Medicare/Medicaid). The volume of services can only be controlled by external controls (rationing) and patient choice ( make 'em pay). Controlling waste and fraud are illusory solutions.

Initial attempts to control costs in a national system will follow the line of least political resistance using feeble and infuriating covert rationing, but in the long run will require explicit rationing as other nations have done. Yes, ObamaCare will have rationing, of the irrational kind.

An excellent source for discussions of these issues is DrRich at covertrationingblog.com, everyone interested in these issues needs to read his explanations and analysis.

Does Canada Really Make Patients Wait?

In the debate about a Government-run National Health Plan, impressions of the Canadian system loom over any proposal. The influence can be subtle, educated, or not. Often it degenerates into the exalted format of childhood arguments:"Does!" "Does not!" "Does too!" etc...

Waiting times for certain tests and surgery are thrown about and highlighted or trashed, but rarely is any data offered. Here is the 2008 Fraser Institute report "Waiting Your Turn", which provides a comprehensive look at the numbers. Take a look at it, some of the best graphs of the overall effects are on pages 57 and 58.

Highlights of the report include an average 8.5 week wait from referral to seeing a specialist, and another 8.7 weeks to receive the treatment recommended by that consultant. One of the shortest waits was medical oncology (think chemotherapy) which was 4.6 weeks from referral to treatment. Overall the wait times nearly doubled compared to 1993 (referral to treatment went from 9.3 weeks to 17.2 weeks in 2008).

One can well argue whether these waiting times are medically significant or not, whether this person or that person might have "had an untoward outcome" as a result.

My point instead is that Canada's medical system is not the health care nirvana that some claim. Canada has rationing by an ever lengthening queue. 

No national health care system can afford to pay for everything, for everyone, always.  All the handwaving about 'efficiencies' and EMRs will not conjure enough cash to prevent rationing, whether open or covert. 

Why Should I Care If Physicians Lose Autonomy?

How does the loss of the conscience clause threaten physician autonomy? How would that affect me?

The loss of the conscience clause is simply one more nail in the coffin, but a crucial one. It marks the transfer of decision making from the doctor and patient to 'someone'.

The someone will be a government medicrat.

If the medicrat has the power to determine what services the doctor must provide, he/she has the power to determine what the doctor cannot provide.

If the doctor is forbidden to provide a service, the patient cannot receive it.

Where does this already happen? Look to Canada, where all medical care comes through the government system, and physicians are prohibited from operating outside the rules. Most Americans know that Canadians can wait months for many tests and surgeries because Canadian doctors have been prohibited from providing care except by the medicrat rules (although a recent court decision has led to cracks in the concrete). If someone wants the hip surgery sooner, they must leave the country rather than wait.

Currently in the USA, a government program or insurance company can decide to "not cover", that is, not pay for a service. The doctor may recommend, and the patient may decide to have a service and pay for it out of pocket. Although this can be inconvenient and expensive, the final decision is made by the patient. The patient preserves his/her autonomy, as does the doctor.

No national health plan can pay for everything, all the time, for everyone, although the politicians will pretend for a time. As expenses run away, the pressure to lower costs will lead to intensified hidden rules and restrictions (covert rationing) and eventually to explicit rationing. The current "not covered" will increasingly morph into "not medically necessary". Will it become forbidden?

Insist that any plan protect this freedom: that when your surgery/test/procedure/consultation is denied or delayed, you have the liberty to pay out of pocket without leaving the country.

Otherwise, expect your bladder difficulties to be treated by Vogon poetry.