Using the 'R' Word

Jim Molpus, for HealthLeaders Media, March 19, 2009

Imagine this scenario: A family in a cramped hospital room. An 88-year-old mother of three boys now all in their 50s. End for mom is near, but the men hope for two or three more years. Maybe enough for mom to see two weddings of grandkids coming up next year.

Mom has multiple comorbidities: diabetic, hypertensive, and frail, but the latest blow is her heart. Not failing enough to allow the doctor to have that obvious conversation about end of life care, but weakening at a predictable rate. A coronary artery bypass would be easily in the conversation a decade ago, but now is risky. The eldest son wants surgery; the other two are unsure and looking for guidance. Whatever the family and patient's wishes, however, the doctors' options are limited by Medicare. Comparative effectives guidelines formed in 2011 make it clear that the chances of a positive outcome are iffy. Medically possible, yes. But that is not good enough anymore.

A health policy wonk's "unnecessary treatment" is another person's life-saving risk. Let's not fool ourselves into sanitizing the end game of the $1.1 billion comparative effectiveness study included in the Obama administration's economic stimulus package. The estimable Carolyn Clancy, head of the Agency for Healthcare Research and Quality, was quoted in the Washington Post this week, claiming the government "is not saying 'Do X or Y.' We're saying here are the facts, and you should have a conversation with your doctor." Common sense, a rare commodity in Washington during any administration, would seem to suggest that $1.1 billion is too high a price to fund a conversation starter.

The study only falls in place as a first step to rationing, the idea that the state will have the science behind it to justify which treatments are appropriate for patients in various stages of life and health. As this analysis in U.S. News & World Report points out, the next step is to create British-style "quality adjusted life year," or some Americanized version of a qualitative grid.

So far, the American public has been too shocked by the continuing economic crisis and other matters to pay attention to the details of the stimulus package that are more far reaching, but we may expect that to change soon. As with the idea that health benefits may lose their tax-free status, or that veterans would end up paying a portion of their own care for war-related injuries (an idea that was quickly abandoned due to overwhelming negative reaction this week), these administration tests and trials are starting to get translated into dollars and their impact on the populace.

While the government and private payers unquestionably spend billions in unnecessary tests and procedures that contribute to the upside-down value of much of American healthcare, the three guys taking care of mom in her last years may not realize the choices soon to be thrust upon them.

Jim Molpus is Editor-in-Chief of HealthLeaders Media. He can be reached at
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