Cost, Quality and Access

"Cost, Quality, Access..." I can still hear it now. My college professor of Social Medicine speaking about the tradeoffs between these three aspects health care. "You can emphasize low cost, high quality OR universal access, but it's nearly impossible to have all three." This was in the heyday of Hillary Clinton's attempt to revise the health care system. She was trying to educate a young student in the perils of American health care. It seemed so abstract, our class sitting there debating the pros and cons of the Oregon Health Care plan, the Canadian health care system, universal vaccination, the rights of citizens, the rights of corporations to make profit, the responsibilities of government for people's welfare and on and on. So abstract.

Well, it ain't so abstract anymore. Every day, I seem to confront the realities and limitations of our health care system. And I'm as perplexed as anyone else as to what the answer is. I'll give you my examples from this past month alone... I one guy who is deciding whether to take a pill for chemo that Medicare covers but is clearly inferior or have to put up 20% of the cost of intravenous chemo that would put him easily into remission but would amount to probably $10,000. He's a machinist and his wife is sick and he has no kids and his insurance sucks. What do you say to this kind of thing? Go broke or take shitty treatment. Or take another patient of mine. He has private insurance, but it only covers labs drawn at a particular university system. The nearest blood drawing area is dozens of miles from where he lives. He's 76, can't see, lives alone and, yes, has a blood disorder that just happens to require very, very frequent blood draws. So, I see him, wait for the labs to be faxed from this other place, try to make some decision in some timely fashion and then enact it. Usually requires a form of injection growth factor that isn't covered by his program to be given in the office unless he wants to cough up that 20%. Oh, but it covers it being "self-injected", but he has bad arthritis, and, yes, did I mention he couldn't see?... well, that's life. Never mind that he fought in the Korean and Vietnam wars and worked as a civil servant for a number of years. Or the Mexican illegal immigrant who rolled into the hospital with a cough and left with the diagnosis of metastatic kidney cancer. Can't get medicines, can't get surgery, can't even get an office visit paid for, can't go home to Mexico. He just waits. And waits. He's a nice guy and so respectful, but I just sit there impotent to do anything. I can't take a huge financial loss to treat him. I can't stop thinking about him. No one wants him, even the university hospitals in our city. Yep. Stinks.

Cost. Quality. Access. Currently, we have the worst of all worlds. We have the most expensive health care on Earth, some 14-17% of GDP going towards health care. We have spotty quality. Yep, you heard it. Yes, we have more MRIs in Maryland than in all of Canada and you have people lined up around the corner to install high tech stents, pacemakers, dialysis, catheters, etc. We've got high tech alright. But, how about infant mortality, or vaccination strategies or public health or just plain lifespan. Based on everything we know about science and public health measures, we do a crappy job of implementing care that would help millions of people. We pay through the nose for a cardiac bypass, but pay primary care docs 10 bucks to spend an hour trying to help us stop smoking or lose weight. We don't go for the most quality for the MOST PEOPLE. We go for the absolute PREMIUM care for a chosen few, adequate care for the majority and severely, disastrously poor care for the chosen slobs. Finally, access. Well, everyone knows about the 30-40 million uninsured. But, the grim fact is that the uninsured utilize even more care sometimes than the insured. They lack primary services and therefore utilize emergency care more frequently. Emergency rooms are packed to the hilt with uninsured patients who use the ER for their primary care, driving up costs enormously, overwhelming docs and resulting in often-disastrous outcomes.

What's the solution? I have no freaking idea. All I know is that people need to be aware of the tradeoffs between these issues. In my opinion, the only way to improve things is to accept that dreaded, hush-hush outcome that has rarely been mentioned for nearly a decade... RATIONING. Yep. Rationing. Any system that provides universal health care for the entire population and doesn't completely bankrupt the Treasury is going to require rationing. It simply has to. But, rationing isn't what you think. It isn't the managed care kind of rationing where some phone tree or technician either argues with you or ignores you in order to minimize your use of the system.

No, rationing is maybe something different. It means taking what we ALREADY know about effective treatments and implementing as many of those as possible FIRST, before turning to more expensive treatments that benefit fewer people. Something akin to the Oregon Health Plan that came about in the 90's. What that plan basically tried to do was to come up with a list of treatements... a list of treatements of all the known medical conditions, bone marrow transplants, diphtheria vaccines, gallbladder surgery, hair removal, etc. Take a panel of medical experts, ethicists, business people, lawyers, government agencies and other stakeholders and come up with a list from 1 to whatever, listing the treatments from most effective to least effective. Most effective might be something like the polio vaccine. Helps everyone, costs pennies. The least effective might be some totally rare experimental bone marrow transplantation for a super rare disease like aplastic anemia. Take that list, take your state budget and find some point on the list where below that point, you just can't pay for the treatments solely by government, because the benefit is outweighed by the cost. Everything above the list is covered by the government. Everything below, well, you're on your own. There is, in effect, "rationing" of care.

Yes, it is fraught with problems. Wealthy people could find ways to circumvent the list. There would be bias in favor of the rich. But, honestly, there already is a many-tiered system of care in this country based on wealth. It's just more opaque and more fraudulent. I've always liked the Oregon Health Plan. Somehow, it just seemed logical and fair and would control cost while providing broad care to the most people with the most beneficial treatments.

But, alas, I don't think we'll get there. Too many stakeholders, too many powerful interests. The states, however, are experimenting with different things in the absence of national leadership. Who knows? Maybe something will happen before the Baby Boomers impoverish the government. I can dream, though. I can dream of a day when I close up my oncology shop, because most cancers have now been prevented by public health measures curbing smoking, excessive drinking and obesity. How people will prevent heart disease and when there will be no more disfiguring breast cancer surgeries or big scars on peoples' chests where their lung cancers have whacked out. Ain't gonna happen. I know that. But I can daydream. Gives me something to think about while I'm pushing more chemo.