This article is more than 5 years old. Information may no longer be current.
As the pendulum swings from overuse to rationing: Facing the hard medical-care choices in orthopedics
Click Here to Manage Email Alerts
|
|
Over the years, the Hippocratic Oath has been amended and or altered to expand its interpretation through classic and modern versions. Even the original oath has been the subject of differing translations and interpretations of the original Greek. While all the pledges are interpretations of the ideas of Hippocrates, there is no single oath taken today by all physicians completing their training.
When I took the Hippocratic Oath, it was my understanding that I was pledging to help the sick to the best of my ability and judgment. At that time, no mention of the cost of providing that care was considered. In the Feb. 27, 2008 issue of the Journal of the American Medical Association, Dr. Ezekiel Emanuel suggested in “The Cost-Coverage Trade-off: ‘It’s Health Care Costs, Stupid’” that the Hippocratic Oath actually contributes to the “overuse” of medical care. He stated that it is often the basis for doing everything for the patient regardless of cost or effect on others. He challenges us to rethink that doctors should be trained “to provide socially sustainable, cost-effective care.”
He is realistic in that article in stating that real health reform and controlling escalating costs in this country will not be pain free. He wrote, “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely ‘lipstick’ cost control, more for show and public relations than for true change.”
A recent study by Thomson Reuters, found that the American health care system is “hemorrhaging” billions of dollars annually through waste. Robert Kelley, vice president of health care analytics there, said that we waste an estimated $700 billion a year — that is one-third of the nation’s total health care expenses. Among the “waste” noted in the report, unnecessary care; fraud; administrative inefficiency; health care provider error; preventable conditions; and lack of care coordination.
The report notes that unnecessary care and fraud account for 59% of the waste. Their versions of unnecessary care include the overuse of antibiotics and certain presurgical lab testing.
As the politicians and experts wade through the proposals and recommendations, they will eventually realize and deal with the fact that the only way current health care reform will have a chance to control the escalating costs of medical care is through allocating and rationing. The original objective of the current health care reform initiatives was to slow down costs, in part through changing physician behavior—since we order the tests and studies and control patient care.
Proposed models
Many of the proposed models advanced having physicians put on salaries to remove some of the financial incentives and to train them to only provide cost-effective care. Other proposals deal with achieving better control on elderly care and the disproportionate health care costs experienced in the last 6 months of life. That debate will involve bioethicists, politicians and lawyers. Part of it will be to redefine and challenge the physician’s role and duty to work for the greater good of society.
Balancing the physician’s traditional role of caring for individual patient’s needs and the funding resources of society will take time. For more on this, I suggest you read Dr. Emmanuel’s article on “Principles for Allocation of Scarce Medical Interventions” in the Jan. 31, 2009 Lancet.
By the way, Dr. Emanuel is a health care adviser to President Barack Obama and brother of Chief-of-Staff Rahm Emanuel. He is a bioethicist, writing extensively about medical care allocation, end-of-life issues and physician-patient relationships. He may play a role in guiding Obama’s team as they begin to address these issues.
Age-related care
In the United States, medicine has resisted the rationing of medical care at any age. So, not surprisingly, nothing is currently in place to control costs as we expand the scope and quantity of coverage, deal with increased longevity of our population and have a constant introduction of new technology and treatments. The limits on what our society can and will pay are being challenged more than ever.
Allocating health care resources within changing demographics and budgetary pressures for Social Security and Medicare as the baby boom generation begins to retire are becoming a reality. In the next 20 years, caring for dementia and Alzheimer’s disease in our aging population alone will test our funding sources. This will raise issues that will take years to deal with in our society. Think of the passions involved in abortion issues. Just imagine the debates over assisted suicide and any form of euthanasia. We recently heard and saw the vociferous reactions to the concepts of “death panels” which were never formally proposed, but are extensions of starting to deal with these issues. We have difficulty rationing care resources like donor organs and limited vaccines. Wait until we have to limit or ration health care related to end-of-life issues.
Changes in orthopedics
Fortunately, in orthopedics we deal with quality of life and enabling people to be more independent and less disabled. As a specialty we will not deal with extending end-of-life issues directly, but our ability to provide care could be limited if oversight committees decide that certain aspects of care are unnecessary.
How further cost-containment measures in the proposed health care reform packages currently before Congress will impact orthopedic surgeons remains speculative at this point. However, future changes in reimbursement from Medicare, the largest purchaser of health care in the country, will occur. Chief Medical Officer at the Centers for Medicare & Medicaid Services, Dr Barry Straube has been instructed by Congress to pay for what is “reasonable and necessary” to control costs.
This phrase has not been spelled out or defined by Congress, industry or medical groups. Much debate will need to take place for a working definition. At this point, cost is not a basis for denial of any service, but “scientific evidence” to support effectiveness can be required. By extrapolating what has occurred in other specialties you can see the direction the reasoning will go as it is applied to orthopedics. New prostheses and hardware designs, robotic and computer assisted procedures, growth factors, arthroscopy in the elderly are just a few examples that will fall under these “to be defined” guidelines.
Cost effective is a term not discussed or yet defined in pending legislation. It will come as an extension of “reasonable and necessary.” It may eventually involve the responsibility to the individual patient balanced by considerations to the society paying for it. Next year will see further debate and definitions for some of the ambiguousness in this phase on our way to health care reform.