The Affordable Health Care Act had its first birthday Wednesday. Despite Republican promises during the November elections to "repeal and replace," recent polling data has shown that a majority of Americans oppose efforts to repeal or water down health-care reform in its current incarnation. Still, the law will not be implemented in its entirety until the end of 2014, and over the next two and a half years, health-care reform will need to stand up to a barrage of attacks from the right.
One thing the Affordable Health Care Act didn't deal with is the way care is distributed through our system of doctors, hospitals, and nurses. But the way health care is delivered has a big impact on patients. TAP talked to M. Gregg Bloche, an expert in health policy and author of The Hippocratic Myth, about our current health-care system and the future of patient care.
In your book, you argue that doctors are already limiting life-saving treatments because society cannot afford them. What are the dynamics of limiting treatment?
One example I give in the book is the story of Sarah. Sarah was an 82-year-old woman who was rushed to the hospital with a heart attack. She was admitted, taken to intensive care, and given the works -- the kinds of treatments that cost thousands of dollars per day. The doctors quickly reach the conclusion that it's not going to work, but they can't say that for sure in a scientific sense. They're at an HMO that has a fixed budget, and they tell Sarah and her daughter that treatment is futile, and they would like to stop taking extraordinary measures and enable Sarah to get comfortable. The doctors tell Sarah and her daughter that they should be making plans, and the daughter flips out. The doctor tells Sarah at one point, have you ever stayed in a really expensive hotel? And Sarah says yes. Well, how much does it cost to stay in a really expensive hotel? Maybe $700? Well, this is a really expensive hotel. This costs thousands of dollars. In the end, though, Sarah gets very aggressive treatment and two weeks later, walks out of the hospital and lives for another year or so.
I think this is a case that illustrates the dynamic of perhaps cognitive dissonance on the part of the doctors. Doctors often times might not be aware that they are setting limits in order to make a go with the budgets. Nevertheless, that's going on all the time. It's more subtle in some contexts, when doctors are not working on fixed-budget HMOs, but doctors know that their economic performance is going to be assessed by budgets.
What are the costs/benefits in how this is playing out?
I think the reality is that we can't afford to pay for every possible clinically beneficial treatment that we are technologically capable of administering. Inevitably, we're going to have to set some kind of limits. The costs of doing it this way are many. Number one, the reality of dishonesty means that dishonesty gets discovered. There is inevitably a cycle of revelation; there are entrepreneurs of revelation, whether they be medical malpractice lawyers or investigative journalists or those who hold legislative hearings. Disingenuity gets discovered. Trust is endangered. Trust in doctors and trust in the health-care system. The kind of anger that was reflected in the "death panels" kerfuffle. If we can't talk about setting limits, but we set them anyway, then we just set the stage for this kind of rage that makes it impossible to do what's necessary for health-care cost control.
Are there circumstances when limiting life-saving treatments is actually a good thing?
Plainly, there are a lot of situations, aside from the economics, that setting some kind of limits on extreme treatments will result in greater comfort. There are times when medical care can go to outlandish extremes, and we impose a great deal of suffering as a result. Those are the situations that the clinical costs outweigh the benefits. But I'm getting at something slightly different, and that is [in] situations based purely on clinical situations, for an individual it makes sense to try to provide additional care, but it's care that society can't afford to pay for.
What role should public debate and the common good play in medicine? We need to face the reality that health care, amongst other things, is the main driver of our long-term federal deficit. I'm disappointed that neither the Obama administration nor folks in Congress have stepped up and told the American people that unless we set limits on health care, we're not going to get control of our long-term deficit. There are a couple of ways we can do this. Number one, changing our financial incentives so that we don't offer these extraordinary rewards for high-technology treatments that yield only marginal clinical benefits. Instead, we offer more generous rewards for biologically decisive treatments. Nowadays, doctors and hospitals buy the latest technology and achieve only slight differences -- say, the MRI scanner that offers slightly better resolution but costs a whole lot more. Now, doctors can make a huge amount of money providing that kind of high-technology cure, but if you prescribe a pill ... you're going to get paid not nearly as much. Number two, ultimately coming up with ways to talk about saying no. I would like to see the president speak openly to the American people about the long-term deficit. To explain the way we would want to see a president talking about global warming, that this is unaffordable over the long haul.
Who should decide what treatments are given to whom? Who's deciding now? Who will decide under health reform? I don't think health-care reform does very much with this problem. I think that the Affordable Care Act is a huge advance. We're pulling in 30 million people into the system, people who have not gotten health care or health insurance. That's a great step forward. But health reform as passed a year ago doesn't do very much about cost control. It sets the stages in some ways, but we don't have a major change in the treatment environment. We don't have a change in tax laws that will ultimately disincentive the purchase of ever more expensive health plans. We need to change how doctors are paid, how hospitals are paid. We need to make the costs more transparent. I think that's one crucial area. The other crucial area will be setting limits on here and now.
What unnecessary demands do doctors face? I think we're putting doctors in the middle because of our contradictions. Two-thirds of the American people say we shouldn't make cuts to Medicare, and two-thirds of the American people say we shouldn't raise taxes. That kind of captures it for me. We want every kind of beneficial care when ourselves or our loved ones get sick. [We] shop at Wal-Mart and look for the best price. Companies that are trying to deliver the best price are concerned about trimming their insurance bills for their employees. So here are doctors in the middle. Doctors are expected by their patients to provide all possible beneficial care, and meanwhile, the payment system is not allowing it. Then we become angry when we discover that doctors have engaged in covert rationing. And if doctors don't engage in covert rationing, we become upset at the growth of health spending. It's an unwinnable position for physicians caught in that situation.
