There was a great deal of controversy two years ago about the supposed imposition of “death panels” in Obama’s health care plan.   Yet, there seems to be no controversy whatsoever about the “death panels” that are implicit in the more than 10 states’ plans to slash Medicaid funding in their states.  Dealing with (real and purported) budget shortfalls, these states are slashing their budgets for Medicaid.  The end result is that indigent and lower middle class  patients will simply be told that there is no money for their care or for care for their children.

Moreover, these states are not doing what was begun in Oregon (I call it the Oregon Plan; Oregon termed it the “prioritized health system”).  Oregon’s Health Service Commission (HSC)  (comprised of clinicians and health professionals) determined how many people get how many illnesses and traumas within the state.  It placed a cost value (using historical data) and an effectiveness value to each trauma.  This also includes conditions that are not currently funded.  Using these data, the HSC ranks all the conditions in order of effectiveness and propensity.  The goal is to provide the most good for the most people, at a given funding level.

(The problem with such a system is when a government deliberately chooses a level that it knows is not adequate.  For example, if the funding for health care in 2008 was $ 100 million, it is impossible to rationally impose such a system with 2012 funding at $ 75 million.  It is clear that such a scenario is not meant to provide the most good for the most people but to deliberately exclude portions of the population from adequate care.)
Let’s look a rationale imposition of such a plan for one particular illness. As you have read here (you can search for “dialysis” on my blog), HR-1 (1972) provided for the nearly completely free care for kidney patients, regardless of their age or their ability to pay.  Over the years, the waiting period for Medicare (the agency that supplies this funding from the Federal government) has delayed the onset of coverage to some 2 years, versus about 9 months when the program began almost 4 decades ago.

With costs for dialysis expected to reach some $ 40 to $ 50 billion (the lower number this year, the higher number no later than FY 2013), clinicians are examining alternatives for patients with multiple conditions.  Using a plan the Renal Physicians Association and the American Society of Nephrology (note that both organizations have overlapping membership) developed to deal with abusive and noncompliant patients, a “medical management without dialysis” plan is being developed for these situations.
People over the age of 75 are now the fastest growing segment of dialysis patients- and they have other maladies including dementia, heart failure, and stroke.  (1/3 of these patients have four or more chronic conditions.)  The result is that many of these patients are not having their lives prolonged, but are spending those days in a hospital rather than home with their families.

Patients are not being sent home (or left in facilities) to die with such considerations, Palliative care is provided.  Physicians are discussing with their patients that dialysis is not a simple treatment plan.  (Just because it is done routinely in an outpatient clinic does not make it so.  A patient’s blood is continually withdrawn from its body for 3 to 4 hours- a total volume movement of 30 to 40 liters of blood (or 6-8 total exchanges) over that time period.  This is repeated three times weekly.  And, this rigorous treatment period does not include travel to and from the clinic. Currently 1 in 5 potential patients withdraws from treatment.)

Moreover, this law (HR-1, 1972)  was originally intended to keep patients alive and productive.  That implicitly means young people and middle-aged people.  (The discussions at the time projected that some 40 patients per million of population, under the age of 55, would be covered.  The program now includes some 400,000 people or more than 1300 patients per million.  Of them 1/3 are over the age of 65.)  It was not intended as a means to extend the life of people in their 80’s and 90’s, with other serious medical conditions.
This needs to be the model for our states.  A census of conditions and costs needs to be developed for each state.  The effectiveness for each treatment has generally been available and can thus be included, without political influence (i.e., using scientific, observational data).  And, given reasonable funding, proper treatment for the most people with the best results can be obtained.

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