HEETH Care

[BTS]

Okay folks - is this what you want? Is it defensible? And this from the brother (surprise) of the White House chief of staff, a special advisor to President Obama on reforming health care.



Link: http://www.ncpa.org/pdfs/PIIS0140673609601379.pdf



Ezekiel Emmanuel MD, Rahm Emmanuel’s brother, who is Barack Obama’s “Special Advisor for Health Policy”, is described by the [1] Huffington Post article as engaged in a very important mission: redesigning the US health care system.

Emanuel and the White House are attempting to reorganize the delivery and reimbursement systems of health care, changing what the types of procedures doctors rely on, making people more aware of disease prevention, encouraging insurance companies to expand coverage, and so on. It is a process rife with sensitivities, trickeries and, of course, the potential for failure. It is not, he insists, impossible.

“It is a complicated process and we have to try and make the choices clear and give people good reasons for making them,” Emanuel explains. “I don’t think that’s an impossible task and thankfully we have one of the great communicators, Barack Obama, at the helm of this ship of state.”



Emmanuel recently authored an article in the Lancet describing the various models of non-market health care rationing. Titled [2] “Principles for allocation of scarce medical interventions”, its is co-authored with Govind Persad and Alan Wertheimer. In it the authors simply review the pros and cons of the various ways of deciding who gets treated and who doesn’t. The allocation mechanisms they discuss are divided into strategies and substrategies. The pros and cons of each are laid out.

Treating People Equally



Lottery

First-come, first served

Prioritarianism



Sickest first

Youngest first

Utilitarianism



Saving the most lives

Saving the most life-years

Saving the most socially useful

Reciprocity (paying back people who have ‘contributed’, such as organ donors)


The authors are not very satisfied with the current metrics used for making medical decisions based on saving the most life-years. Both the “Quality-adjusted life-years” model and the “Disability-adjusted life-years” have shortcomings which they believe can be addressed by another model of their own: “The complete lives system”, which takes all the factors into account. They write:



Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles: youngest-first, prognosis, save the most lives, lottery, and instrumental value. … When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated … the complete lives system is least vulnerable to corruption. Age can be established quickly and accurately from identity documents. Prognosis allocation encourages physicians to improve patients’ health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates.

Under this system, patients would receive scarce care according to the graph shown below.



The paper concludes: “the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives. In pandemic situations, it also allocates scarce interventions to people instrumental in realising these four principles. Importantly, it is not an algorithm, but a framework that expresses widely affirmed values: priority to the worst-off, maximising benefits, and treating people equally. To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo.”



What’s not mentioned anywhere in the discussion, except by implication is the identity of the narrator. Who is the “we” in “Principles for allocation of scarce medical interventions” that decides who gets scarce medical care? The answer is tangentially provided in the paper itself, which writes that “the complete lives system is least vulnerable to corruption”.The “we” is a system; a system that can possibly be corrupted; hence Dr. Emmanuel’s efforts to design one in which such distortions will be held to a minimum.



Ultimately health care reform is as much about politics as it is about medicine. The discussion in Dr. Emmanuel’s paper is incomplete if limited to pure public health considerations. Politics is central to the whole issue. Whatever “guidelines” are chosen, however rational, however humane, can never implement themselves. Human beings in positions of power are required to do that. And while it is important to note that even under the current system these decisions are being made by someone or by some consensus, it is also vital to realize that in any “health care reform” effort, one of the principal outcomes is to shift the power to make those decisions to someone else. That may not be a fit subject for the Lancet, but it is the elephant in the operating room in the national health care debate.

[Accountable]

Thanks for digging this up, BTS. It's enlightening. It troubles me that President Obama would hire this guy to be special advisor for health care at the Office of Management and Budget. While no one is saying Congress will require to use the Complete Lives system to prioritize care in the current bill, who is to say it won't find its way into the system in the future, if we allow the government to take over the healthcare system?

[chonsigirl]

What an interesting article. And a surprise who wrote it, haven't heard mention of it on any news program yet.

Saving the most socially useful


I find that a disturbing statement, who would be set up as the moral and ethical decision maker for this?

[spot]

chonsigirl;1228600 wrote: Saving the most socially useful I find that a disturbing statement, who would be set up as the moral and ethical decision maker for this?
Perhaps I mistook the article but isn't that one of the options rejected? It's certainly one of the criteria built into current US health-care given the utilitarian equation rich = socially useful. The author is analysing alternative distribution patterns.

[Accountable]

A Modest Proposal by Jonathan Swift - Full Text Free Book

[chonsigirl]

spot;1228604 wrote: Perhaps I mistook the article but isn't that one of the options rejected? It's certainly one of the criteria built into current US health-care given the utilitarian equation rich = socially useful. The author is analysing alternative distribution patterns.


Thank you spot for pointing that out to me.

May I ask, spot, is there any component like this in the health system there?

[Accountable]

chonsigirl;1228729 wrote: Thank you spot for pointing that out to me.



May I ask, spot, is there any component like this in the health system there?
The pdf that's linked indicates that they do use it. They call it instrumental value. It's in Table 2 of page 5.



Youngest-first;

prognosis; save the

most lives; lottery;

instrumental value, but

only in public health

emergency



http://www.ncpa.org/pdfs/PIIS0140673609601379.pdf

[spot]

chonsigirl;1228729 wrote: Thank you spot for pointing that out to me.

May I ask, spot, is there any component like this in the health system there?
The priorities toward which resources within the National Health Service are directed are continually discussed and refined. That philosophical article in the Lancet is one of many, it's discussions like that which inform high level decision-making here.

What I've tried several times to get across on ForumGarden is that we don't have either/or healthcare, it's not NHS or nothing. We have the entire set of US options plus the NHS. Anyone with the resources can buy private health-care insurance and be treated by private practitioners in their surgeries or in private hospitals, they can pay directly if they prefer pay-as-you-go to insurance, employers often add private health-care packages to their packages. The NHS is the safety net which catches the people who can't afford any of that. Health care in the UK currently costs 9% of our far lower GDP, pretty close to a half of the proportion America coughs up, God only knows how badly you've screwed up in allowing the profiteers to suck your bones dry or why you've allowed it to happen in the first place. But it's your country, it's your health, either you can summon up the votes to retain what change you're getting or you can carry on suffering. It's a purely national problem and it's entirely your own.

As for paying for something I don't personally use that's common for any of the national services. I pay for education whether I have children at school or not - I pay for it whether I have children or not. I pay for the police whether I benefit from their activities or not. I pay for the armed forces despite deploring their existence, I pay for road maintenance despite not driving, I pay whatever derisory sum I'm invited to contribute to science research - that's the general nature of taxation. So do Americans. Why health care should be exempt I can't imagine.

[chonsigirl]

Thank you for your explanation, sopt. The basic components sound similar to the one proposed here. Elective insurance and/or insurance for all. (although it will be made mandatory here, I do not know how they can do that feat)

I think Health Care enters the realm of morals/ethics, on a different level than paying for the military/police.

[spot]

chonsigirl;1228797 wrote: I think Health Care enters the realm of morals/ethics, on a different level than paying for the military/police.Undoubtedly you're right chonsi, but you didn't pick the hard question - how does it differ from education? That's an issue I've tried several times to get addressed here without success. Why do tax payers contribute to public education regardless of whether they have children or not, whether their children are at school or not, whether their children are educated privately or not? And given that they do, why would they not also pay to maintain the general health of the population given that the general health of the population benefits the economy to more or less the same extent as compulsory education does?



chonsigirl wrote: Elective insurance and/or insurance for all. (although it will be made mandatory here, I do not know how they can do that feat)On a point of information, the UK does it with compulsory National Insurance contributions too. That doesn't necessarily pay the entire bill for the service but it's part of the design adopted in the 1940s.

[chonsigirl]

They debate that question here also, with the voucher system. The general populace pays for taxes that include services including education. I do not think that is right either, parents should have choice whether their children attend public or private school. And also, why should one pay those taxes if they have no children any longer in the system. In most instances, education is a state/local issue, with broad federal laws about specific things. (like the No Child Left Behind)

The term General Health-it is an ethical/moral decision. And then the question arises, where does that enter Constitutionally protected rights, such as First Ammendment and religion?

It is a complex question, and a political system alone cannot resolve it.

[spot]

chonsigirl;1228809 wrote: They debate that question here also, with the voucher system. The general populace pays for taxes that include services including education. I do not think that is right either, parents should have choice whether their children attend public or private school. And also, why should one pay those taxes if they have no children any longer in the system.The voucher system doesn't affect whether the general population pays for public education. As you say, that's a choice for society at large. The US choice on that issue is yes it should. I'd be very interested to hear your view on whether that decision's the right one or not. Education couldn't be compulsory if it weren't paid for on that basis, unless you can think how that would work - I can't.

As for "It is a complex question, and a political system alone cannot resolve it" it's already been decided by popular vote. In the UK it would be called a manifesto commitment. The man said vote for me and I'll do this this and this, take it as a package or don't vote for me. They voted for the man and the package he was promising to implement.

[Accountable]

United Kingdom NHS



FRONTLINE: sick around the world: five capitalist democracies & how they do it | PBS

Percentage of Gross Domestic Product (GDP) spent on health care: 8.3



Average family premium: None; funded by taxation.



Co-payments: None for most services; some co-pays for dental care, eyeglasses and 5 percent of prescriptions. Young people and the elderly are exempt from all drug co-pays.



What is it? The British system is "socialized medicine" because the government both provides and pays for health care. Britons pay taxes for health care, and the government-run National Health Service (NHS) distributes those funds to health care providers. Hospital doctors are paid salaries. General practitioners (GPs), who run private practices, are paid based on the number of patients they see. A small number of specialists work outside the NHS and see private-pay patients.



How does it work? Because the system is funded through taxes, administrative costs are low; there are no bills to collect or claims to review. Patients have a "medical home" in their GP, who also serves as a gatekeeper to the rest of the system; patients must see their GP before going to a specialist. GPs, who are paid extra for keeping their patients healthy, are instrumental in preventive care, an area in which Britain is a world leader.



What are the concerns? The stereotype of socialized medicine -- long waits and limited choice -- still has some truth. In response, the British government has instituted reforms to help make care more competitive and give patients more choice. Hospitals now compete for NHS funds distributed by local Primary Care Trusts, and starting in April 2008 patients are able to choose where they want to be treated for many procedures.

An excellent interview goes into a little more detail

FRONTLINE: sick around the world: interviews: nigel hawkes | PBS

[spot]

Accountable;1228838 wrote: Young people and the elderly are exempt from all drug co-pays.That was a helpful post Acc. Just to add to this sentence, there's a cap on the total drug co-pay from any individual NHS user of $200 a year.

[chonsigirl]

spot;1228833 wrote:

As for "It is a complex question, and a political system alone cannot resolve it" it's already been decided by popular vote. In the UK it would be called a manifesto commitment. The man said vote for me and I'll do this this and this, take it as a package or don't vote for me. They voted for the man and the package he was promising to implement.


Well, you know how they promise anything to be elected. And I didn't vote for him. And he still hasn't impressed me, sorry Nomad.

I do not know what will happen before the next set of elections. And it is a complex situation-the tea parties and town halls are the grass root movements opposing the proposed changes to the system.

I shall look up tonight or tomorrow a definition of manifesto in UK terms, to see what is the comparison.

[spot]

chonsigirl;1228865 wrote: I shall look up tonight or tomorrow a definition of manifesto in UK terms, to see what is the comparison.


CONSERVATIVE MANIFESTO .COM - 101 Years of Conservative Party Policy is a good starting point for that, to get the flavor of them.