what was lost

This week’s Times magazine has an excellent (and long) article on the medical ethics battlefield that memorial hospital in new orleans became in the hours, months, and now years, after katrina. amazingly, it doesn’t throw the blame on anyone (i say ‘amazingly,’ because the scene at memorial was truly apocalyptic: overweight patients left behind, families of patients turned away, doctors administering lethal doses of morphine as the electricity, and then patient respiratory machines went out); instead, it represents a clearheaded call for resisting/rejecting the insularity and opaqueness of medical ethics boards and a plea for more thorough emergency action plans. read it. and give Dr. Sherry Fink a Pulitzer. Or better yet: put her on the new MedPAC advisory committee. This is what journalism should be:

“Father John F. Tuohey, regional director of the Providence Center for Health Care Ethics in Portland, Ore., said that there are dangers whenever rules are set that would deny or remove certain groups of patients from access to lifesaving resources. The implication was that if people outside the medical community don’t know what the rules are or feel excluded from the process of making them or don’t understand why some people receive essential care and some don’t, their confidence in the people who care for them risks being eroded. ‘As bad as disasters are,” he said, “even worse is survivors who don’t trust each other.’ “

all together now…

the times’s excellent “room for debate” blog has a great roundtable on health care reform, highlighting the importance of adjusting doctors financial incentives to lower costs in an industry that receives one out of every 5 dollars americans make. i distill some of the arguments/suggestions/rants below:

Dr. Fisher (Dartmouth): “An underlying cause of this overuse [of certain diagnostic or surgical procedures] is a fragmented and uncoordinated health care system where each physician only focuses on a tiny piece of the patient’s care. Most physicians, even those in primary care, have become “partialists.” And the payment system that rewards overuse by physicians and encourages hospitals to compete in a local medical arms race to offer every possible profitable service.”

Dr. Pho (N.H): “Physician payments need to be divorced from the volume of care and instead associated with evidence-based quality measures and a reduction in medical errors. [D]octors should be “incentivized” to take the time to counsel and guide, along with improving their communication with patients, not only in person, but over the phone and on the Internet.”

there’s more below…

rational rationing

an excellent piece by david leonhardt in the times suggests that, like most issues in the larger health care reform movement, debate over the equitable distribution of scarce health care resources becomes a battle of words, not ideas. the result is something petty and counterproductive: “The choice isn’t between rationing and not rationing.” Leonhardt writes. “It’s between rationing well and rationing badly. Given that the United States devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it’s hard to argue that we are now rationing very rationally.”

in related news, bob dole and tom daschle save health care reform? seriously?

medicare

any real reform to our nation’s health care system must take a close look at medicare, the current health “safety net” for millions of americans. tyler cowen’s piece in the sunday business times argues for the creation of an independent medicare expense review board, an idea supported by the white house. before any new public plan is implemented, cowen asserts, we need to get the costs of medicare down:

“67 percent of Americans believe that they do not receive enough treatment and [only] 16 percent believe that they have received unnecessary care. If the Obama administration covers more people with government-supplied or government-subsidized insurance, the political support will broaden for generous benefits, their continuation and, indeed, expansion of current expenditures.”

The line of thinking goes like this: if we are already over-treating patients (and we are), and unnecessary care is responsible for skyrocketing costs, we will see expenditures spiral out of control if we treat the 67 percent of the nation who don’t think they get enough care like the 1/3 who do. as a solution, Cowen proposes–coupled with the medicare review board–a one-time tax on health benefits. OK. That creates incentives for both the public and private sector to demand more efficient, lower cost care… but it will also undoubtedly lead to medicare cuts (something Obama proposed on friday as a possible source of funding for a new public option), which creates an even higher, perhaps unscalable, barrier to care for groups like the homeless, drug users, and illegal immigrants who depend on hospitals with medicare support.

i reject the premise that fiscal responsibility and moral obligation are mutually exclusive in the ongoing health care reform debate. we can have equal and efficient care–politicians need to realize that they are the ones who must make sacrifices, not their constituents.

treating cancer as a chronic disease

breast cancer cells

(b/c apparently it’s health care week on this blog) In a recent nature publication, a researcher suggests that we eschew the “war on cancer” paradigm that has dominated treatment regimes for 20+ years. why do we try to kill all the cancerous cells in the short term in a patient, robert gatenby asks, if we know the cancer is fatal and doctors can prolong life by treating the disease chronically? gatenby’s essay asserts that by eliminating only the most active and destructive cells, and leaving a reservoir of active cancer cells in the patient, we can perhaps limit the number of cancerous bodies resistant to chemo or radiation.

of course, there should be continued “magic bullet cure” research going on, and this is a tough ethical question to consider as well, but such I think chronic treatment has a positive secondary effect: it forces more patient-doctor interactions and promotes (often more cost- and treatment- effective) lifestyle changes in the patient. it attempts to break down the larger, more expensive “disease as something to be treated” health care paradigm and shift us more towards a healthier “managed care” way of thinking.

obama reads his new yorker

blogs are abuzz over the news that barack made his closest advisors read an excellent article by dr. atul gawande on the skyrocketing health care costs tied to the entrenched view of insurance companies that profits, not–you know–better patient health, should be a doctor’s paramount incentive. the president should add a previous gawande article to his advisors’ must-read list. it takes a slightly different, but equally pointed, argument–we can’t scrap the entire system, gawande says:

[b]ut we can build a new system on the old one. On the start date for our new health-care system—on, say, January 1, 2011—there need be no noticeable change for the vast majority of Americans who have dependable coverage and decent health care. But we can construct a kind of lifeboat alongside it for those who have been left out or dumped out.

here’s a suggestion: let the public option first insure all children. we already have SCHIP (= kiddie medicare), and this is a population that needs a safety net. (can we please stop making parents choose between bankruptcy and their child’s health?) if it works, great, you can then keep them in the system as they turn eighteen and extend the option to the greater population.

from: yrstruly

maternal mortality in africa

“Why don’t we have a global fund for maternal health, like the one for TB, malaria and AIDS?” A doctor asks the author of the lead article in sunday’s times, a sobering look at the (non)treatment of pregnant women in Africa.

When volunteers with minimal training are performing caesarean sections, when 13,000 mostly teenage mothers die per year, when overcrowded orphanages have a new mouth to feed almost on a daily basis, improvements in prevention campaigns–not just the dispersal of treatment–become essential. (In its first meaning: absolutely necessary, fundamental.) The solutions go beyond the “education” or “empowerment” of women–beautiful words or ideas often (but not always) lacking measurable action: frequent blood pressure checks, vitamins or food supplements, and pre-birth “waiting hospitals” should be expected, not exceptional, services for these women.

But what should a hypothetical UN or IMF program do about those women who never leave their homes for their child’s birth, like the Maasai teenage mothers I met two summers ago? I can point to a few paths forward: increased training and certification programs for community midwives, better basic hygiene and nutrition support, church- or community-supported women’s health education groups.

The stopgap efforts of physicians and volunteers in Tanzania are admirable, but further national or international aid should take steps to expose the government’s blindness to the systemic issues contributing to this disturbing trend, and demand political and economic investment in the future of the young women of Tanzania.