Northwest Indiana Discussion

The lead editorial in the Wall Street Journal today states:

Speaking to the American Medical Association last month, President Obama waxed enthusiastic about countries that "spend less" than the U.S. on health care. He's right that many countries do, but what he doesn't want to explain is how they ration care to do it.

Take the United Kingdom, which is often praised for spending as little as half as much per capita on health care as the U.S. Credit for this cost containment goes in large part to the National Institute for Health and Clinical Excellence, or NICE. Americans should understand how NICE works because under ObamaCare it will eventually be coming to a hospital near you.

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President Barack Obama speaks about health care during a town hall meeting at Northern Virginia Community College last Wednesday.
The British officials who established NICE in the late 1990s pitched it as a body that would ensure that the government-run National Health System used "best practices" in medicine. As the Guardian reported in 1998: "Health ministers are setting up [NICE], designed to ensure that every treatment, operation, or medicine used is the proven best. It will root out under-performing doctors and useless treatments, spreading best practices everywhere."

What NICE has become in practice is a rationing board. As health costs have exploded in Britain as in most developed countries, NICE has become the heavy that reduces spending by limiting the treatments that 61 million citizens are allowed to receive through the NHS. For example:

In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer. This followed on a 2008 ruling against drugs -- including Sutent, which costs about $50,000 -- that would help terminally ill kidney-cancer patients. After last year's ruling, Peter Littlejohns, NICE's clinical and public health director, noted that "there is a limited pot of money," that the drugs were of "marginal benefit at quite often an extreme cost," and the money might be better spent elsewhere.

In 2007, the board restricted access to two drugs for macular degeneration, a cause of blindness. The drug Macugen was blocked outright. The other, Lucentis, was limited to a particular category of individuals with the disease, restricting it to about one in five sufferers. Even then, the drug was only approved for use in one eye, meaning those lucky enough to get it would still go blind in the other. As Andrew Dillon, the chief executive of NICE, explained at the time: "When treatments are very expensive, we have to use them where they give the most benefit to patients."

NICE has limited the use of Alzheimer's drugs, including Aricept, for patients in the early stages of the disease. Doctors in the U.K. argued vociferously that the most effective way to slow the progress of the disease is to give drugs at the first sign of dementia. NICE ruled the drugs were not "cost effective" in early stages.

Other NICE rulings include the rejection of Kineret, a drug for rheumatoid arthritis; Avonex, which reduces the relapse rate in patients with multiple sclerosis; and lenalidomide, which fights multiple myeloma. Private U.S. insurers often cover all, or at least portions, of the cost of many of these NICE-denied drugs.

NICE has also produced guidance that restrains certain surgical operations and treatments. NICE has restrictions on fertility treatments, as well as on procedures for back pain, including surgeries and steroid injections. The U.K. has recently been absorbed by the cases of several young women who developed cervical cancer after being denied pap smears by a related health authority, the Cervical Screening Programme, which in order to reduce government health-care spending has refused the screens to women under age 25.

We could go on. NICE is the target of frequent protests and lawsuits, and at times under political pressure has reversed or watered-down its rulings. But it has by now established the principle that the only way to control health-care costs is for this panel of medical high priests to dictate limits on certain kinds of care to certain classes of patients.

The NICE board even has a mathematical formula for doing so, based on a "quality adjusted life year." While the guidelines are complex, NICE currently holds that, except in unusual cases, Britain cannot afford to spend more than about $22,000 to extend a life by six months. Why $22,000? It seems to be arbitrary, calculated mainly based on how much the government wants to spend on health care. That figure has remained fairly constant since NICE was established and doesn't adjust for either overall or medical inflation.

Proponents argue that such cost-benefit analysis has to figure into health-care decisions, and that any medical system rations care in some way. And it is true that U.S. private insurers also deny reimbursement for some kinds of care. The core issue is whether those decisions are going to be dictated by the brute force of politics (NICE) or by prices (a private insurance system).

The last six months of life are a particularly difficult moral issue because that is when most health-care spending occurs. But who would you rather have making decisions about whether a treatment is worth the price -- the combination of you, your doctor and a private insurer, or a government board that cuts everyone off at $22,000?

One virtue of a private system is that competition allows choice and experimentation. To take an example from one of our recent editorials, Medicare today refuses to reimburse for the new, less invasive preventive treatment known as a virtual colonoscopy, but such private insurers as Cigna and United Healthcare do. As clinical evidence accumulates on the virtual colonoscopy, doctors and insurers will be able to adjust their practices accordingly. NICE merely issues orders, and patients have little recourse.

This has medical consequences. The Concord study published in 2008 showed that cancer survival rates in Britain are among the worst in Europe. Five-year survival rates among U.S. cancer patients are also significantly higher than in Europe: 84% vs. 73% for breast cancer, 92% vs. 57% for prostate cancer. While there is more than one reason for this difference, surely one is medical innovation and the greater U.S. willingness to reimburse for it.

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The NICE precedent also undercuts the Obama Administration's argument that vast health savings can be gleaned simply by automating health records or squeezing out "waste." Britain has tried all of that but ultimately has concluded that it can only rein in costs by limiting care. The logic of a health-care system dominated by government is that it always ends up with some version of a NICE board that makes these life-or-death treatment decisions. The Administration's new Council for Comparative Effectiveness Research currently lacks the authority of NICE. But over time, if the Obama plan passes and taxpayer costs inevitably soar, it could quickly gain it.

Mr. Obama and Democrats claim they can expand subsidies for tens of millions of Americans, while saving money and improving the quality of care. It can't possibly be done. The inevitable result of their plan will be some version of a NICE board that will tell millions of Americans that they are too young, or too old, or too sick to be worth paying to care for.

Of course there will be rationing. I think they will do it thru a back door way however. I think they will use the Canadian model where delays in care create a natural rationing that keeps cost lower. They will try to keep away from outright rejecting care (an argument they use against insurance companies) but costs will be kept down thru delays in care.

Currently there are doctors that opt out of the Medicare and Medicaid programs. They refuse to provide the service for the low fees and length of time it takes for them to get paid. If the federal government has their way and lowers payments further, there will be even more providers that opt out of the program. Naturally driving up wait times as those that remain in the program are buried in patients. Wealthy (and middle class) canadians come to the US because of the wait times in the Canadian Healthcare System. In many areas there are not enough doctors and they literally use lotteries to decide who gets to see the doctor immediately.

Certain drugs will certainly make the Government programs, with others left out. To be fair however, this is already being done by individual insurance companies as well. Look at your insurance companies prescription formulary and you will find drugs in a number of categories that determine their coverage. Generics, branded drugs, premium drugs and non-formulary drugs. For the non-formulary drugs you are on your own. Again someone else is making the judgement of what is most cost effective for your illness. Their having those drugs be non-formulary makes them unavailable to everyone but the wealthy. So it is being done already by insurance companies.

The truth is if we are going to reign in costs, there is going to have to be some sort of rationing. If we are going to keep the type of care we are used to, the costs are going to continue to rise. It's a double edged sword. Many americans are being priced out of healthcare, but aren't willing to give up the type of care we are used to. Should healthy young americans be forced to subsidize healthcare for older citizens dealing with age related disease in order to keep it affordable for seniors? I personally don't believe so, but at the same time each of us is going to age. Our opinions will probably change when we are 75 and unable to afford insurance. But if plans are made affordable to seniors, there are no other choices than to either ration care or pass those costs on to less risky citizens. The costs just don't go away .... and are only going to go up as the baby boomers retire.

Not so!

It would dramatically cut healthcare costs if a cap were placed on malpractice recoveries. Frequently doctors pay $250,000 to $1,000,000 a year for malpractice insurance. Hospitals and clinics pay considerably more.

Pharmaceutical companies pay much more.

Doctors prescribe tests that they know are unneeded but protect them in case of a malpractice suit. Some of these tests cost $1,000 to $15,000 each.

Instead of rationing medical therapy, the government should limit lawyers.

That is easy to say until you are touched by a true case of malpractice. Take Indiana for example, which is actually one of the hardest states for a malpractice suit. Indiana is capped at $1 Million dollars. Which on face value seems like a lot until you are faced with a situation where you need care for the rest of your life.

How would you be able to support a loved one or even yourself that received permanent injury? How would your kids survive if it happened to you? God forbid you wind up with brain damage and end up in a care facility at $300,000 per month. Or you die because a doctor was negligent and your family has to replace a lifetime of wages.

Can you put any dollar value on the life of the patient of the ENT Doctor that disappeared? The doctor diagnosed a condition without ever running tests that he billed the patients insurance for. It turned out to be cancer instead of another condition and it was not caught by another doctor until it was too late.

There is definitely a difference between those that scam the system and those that have been truly wronged by medical care.

And just capping malpractice is not going to cut costs enough to reduce healthcare substantially. We live in a society where we spend extremely high amounts of money for treatment of elderly patients and those with terminal disease. Should we spend $60,000 to give an 87 year old a pacemaker? Should we spend a million dollars on treatment of a stage 4 cancer patient? Should an 50 year old alcoholic get a liver transplant for a million bucks? The ability to treat some of these illnesses has been found thru science, but is there a point we can't afford to pay for it?

Limiting legal fees would cut healthcare costs dramatically right down the line.

Even in the rare and most extreme case, such as mattlapp's, it doesn't in any way justify 40% for the lawyers or several million dollars in legal fees.

I agree with you. The wealthy are not the ones being limited, which is how it should have been all along.

There just is very little common sense in our legal system anymore. An old woman who spilled her own coffee on her from McDonalds and got burned won millions of dollars in her lawsuit. I am sure she didn't need that much to care for herself or that her injuries were the fault of McDonalds. She was trying to drive and drink hot coffee at the same time and couldn't. Now, people pay more for their Big Macs to compensate for her stupidity. Makes no sense at all.

In the same way, doctors can't be expected to fix everything. People don't take care of their bodies, and when the doctors can't fix them, they want to rob the medical system for it.

If something has to be "capped" then it should be the amount of financial compensation in the legal system, not medical care for others.

Again it's easy to say that the fees are extreme until you need the service. Don't think for a second that the Doctor's attorneys paid for by his malpractice insurance aren't going to try and crush the victim. The insurance companies have very high paid in house legal teams looking to wear down the plaintiff.

Some of those trials take 1000's of hours of the Law Firms time, laying out $100,000 for expert testimony and years before trial because of the legal system. Only to have it stretched out further on appeal.

You are being rather subjective about whether they earn their money or not. Do you think their skill level at the job of a top trial attorney making $4 Million a year is any less than the $4 Million a year Neurosurgeon?

Exactly how much do you feel is fair?

You list one case that is excessive. What about the 1000's where people have been genuinely damaged by the negligence of doctors or hospitals? You can't toss the entire system out because of a few egregious judgments.

Please explain what you mean by the wealthy are not the ones being limited, which is how it should have been all along?

Putting a cap on medical malpractice lawsuits is not the answer unless there is fairness. There are many people who are compensated unjustly. When one sustains the need of life time medical bills, the money simply is not enough to sustain them throughout their life. There needs to be a medium. On another note, many malpractice cases would not even happen if the AMA screened the doctors better. Many should not even be practicing and as a result the patient suffers. It is a much bigger problem than most people know.

Mattlap, this is a great explanation of rationing care and I admire your knowledge of the topic. Re:Medicare/Medicaid doctors, exactly a double edge sword. There are already cuts in the Medicare Advantage Care plans for doctors who specialize, and the charges they can apply for imaging. My understanding is that the reimbursement for these services will be cut with the reason being provided is that these cuts will help to increase funding availablity for the new public plan. I agree, doctors will begin to withdrawl from being a Medicare approved doctor and strickly practice for persons who can pay on their own, or have insurance plans that cover the expenses.

I have far more confidence in doctors than I do in bureaucrats.

The article in the Wall Street Journal at the top of this thread describes life saving drugs that are limited by British bureaucrats. Only treating macular degeneration in one eye so that the other eye goes blind is outrageous.

Prohibiting Arecipt for early stage Alzheimer's disease is stupid. That is when it is the most helpful.

Controlling legal costs by controlling malpractice verdicts makes sense. There could be an arbitration board for extreme cases like Mattlapp described.

Well, I wasn't going to sit here and cite many different cases. I used that as an example of how unfair the judicial system has become.

What I meant by the wealthy aren't the limited ones has already been explained in the thread discussion about jubilees taught in God's Word. God teaches many ways on how to remain humble, like the Feast of Tabernacles. For one week every year, people of all classes were made to go live in tents, as to always remember that we area all created equally.

This abuse has gone on for generations, and it has become a very complex issue. There are no simple answers. Our capitalist society has not abased the pride, arrogance and other harmful qualities in powerful people.

Insurance companies here in the United States already make this choice for their policy holders. By placing expensive new drugs on the non-formulary list they make them out of reach for most patients. By pricing them out of range they force patients to have to make do with lesser drugs. It is rationing just the same no matter how you look at it.

In Indiana there is an arbitration board that does have to approve any malpractice suit before it can move to the courts. However the board is made up 100% by doctors. Doctors that might have been judged by a similar board in the past, or potentially face in the future. If you had to guess. Who's interests do you think they are looking out for?

The healthcare industry deserves immense praise and credit for what they have accomplished.

At the end of WWII, life expectancy was 64 for those who died of natural causes, Today, life expectancy is 78.

Any other industry that increased life expectancy of all of us by 20% would be held in respect and awe.

Instead, the response of our politicians is "Sure, we all live 20% longer, but it costs too much. We could be spending that money on a stimulous package to build a high speed railroad between LA and Las Vegas or a viaduct under a highway for turtles."

I say keep our healthcare system saving lives and developing miracle drugs as in the past and let the lawyers and politicans go to hell!

While there have been tremendous advances in healthcare, the costs have gone up far quicker.

Healthcare costs have increased 8x since 1980. In that same time frame $1 adjusted for inflation would be $2.58. So healthcare costs have risen 3.2 times faster than the rate of inflation. That is a pace that is unsustainable, and prices more and more citizens out of healthcare.

I believe there are ways to reign in costs without government forcing insurance based healthcare out of business. But those costs do have to be reigned in one way or another.