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View Diary: Science Friday: The Breath of Life (138 comments)

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  •  Allocate by 'Quality Adjusted Life Years' (6+ / 0-)
    Recommended by:
    elfling, rktect, madaprn, Fabian, AyLian, anais

    Excellent diary. It gets to the heart of what the problem really is, as opposed to the typical shrill arguments of "the insurance companies should pay" or "the government should pay."   Guess what folks -- they don't get that money from elves, they get it from us.

    The nature of the market for drugs (and well, any medical services) is that demand is basically unlimited, but supply is finite.  Cut out all the "waste, fraud and abuse" you want, and you'll still need to make tough choices.

    Personally, I thought Oregon was on the right track when they tried to allocate health care expenditures on the basis of impact -- net increase in health per dollar spent.

    A professor of mine, Richard Zeckhauser, used to use the term "quality adjusted life years", which I kinda like for this.  Basically, you'd add up the number of quality years that a drug or procedure could result in, multiply by the number of people, and voila, you could prioritize.  So a treatment that for someone with 70 years left to live got priority for one with 7 years left, and a treatment that led to full recovery got priority over one that only led to a marginal increase in the patient's condition.

    So in summary, when it comes to public funding, we do something like this:

    1. Figure out the amount we want to spend
    1. Prioritize by quality adjusted life years
    1. Do it

    It ain't easy, since this means that some people are frankly going to be screwed out of treatment -- perhaps including some of the folks mentioned in this diary.   But at least it ensures that at whatever level of funding we pick, we're getting the most bang for the buck.    

    Think more people should get treatment?  Fine, then increase the amount of funding.  But force yourself to be honest, and go through the prioritization in # 2, or admit that you're willing to get less health care per dollar spent.

    (Note -- this just focuses on the straightforward case of public funding, not private, corporate, etc.)

    •  this is not acceptable to me. (6+ / 0-)
      Recommended by:
      mbc, nyceve, lezlie, BlueGoo, catleigh, cohenzee

      if someone needs life-saving treatment, then the number of dollars they have is moot. prioritizing it by how many "life years" they would get i think is not really humane, especially not for the people who don't make the cut for whatever reason.

      I keep thinking about that poor lady in texas who was conscious, but her hospital pulled the plug on her anyway because they didn't want to front another month of treatment which was all she had left to live anyway.

      I'm kind of stalling for time here...They told me what to say. George W Bush, 03-21-2006 10:00 EST Press Conference

      by Tamifah on Fri Jul 21, 2006 at 04:45:42 AM PDT

      [ Parent ]

      •  Pick the state you live in carefully (7+ / 0-)

        the shit the healthcare field pulls routinely in Texas, for example, would be prosecutable (is that a word?) here in Ohio.

        •  this should be changed (3+ / 0-)
          Recommended by:
          Hlinko, nyceve, BlueGoo

          everyone has the same right to live no matter what state they are in.

          I'm kind of stalling for time here...They told me what to say. George W Bush, 03-21-2006 10:00 EST Press Conference

          by Tamifah on Fri Jul 21, 2006 at 05:07:25 AM PDT

          [ Parent ]

          •  I think we're talking about two different things (4+ / 0-)
            Recommended by:
            ohwilleke, elfling, Fabian, AyLian

            Yes, everyone has the right to live, but... you understand that we don't have infinite dollars, right?  

            And assuming that we don't have infinite dollars, then at some point we need to figure out how to allocate them, right?

            Unless you can find a way to create infinite dollars, there's no way to avoid this.

            The problem is that we as a society generally are far more emotional and reactive than rational when making these choices.  

            We read about a woman in Texas whose plug was pulled, and who was denied another month to live, and we're understandably shocked and apalled.  But would you pay for that treatment if it meant denying pre-natal care to a hundred expectant mothers?  Or deny immunizations to a thousand newborns?

            In an ideal world, yes, it should be different.  Money and health care should be infinite.  And in an ideal world, I should be 6'4", driving a Rolls Royce, and dating Keira Knightley.  But here in the world of reality, we need to make choices.

            If you've got a better plan for the world we live in, I'm all ears.  

          •  End-of-life concerns is a great topic for discuss (7+ / 0-)

            I know my dad's last weeks were a nightmare in the hospital. The procedures to keep him going seem barbaric--do you know how many people die with limbs amputated in their last few weeks that only give a short reprieve? Hell, I hope I don't die suffering from an amputation added on in the last month as "treatment".

            I have doctors in the family, and their point is that the most money is spent on prolonging the last few weeks of life. Hundreds of thousands to help someone live an extra two weeks--lying mostly drugged in a hospital.

            I say we spend money on research for cures, but also on research on how to make the last weeks of life more humane. Spend money on hospices, and life and death would be much better. Or for those who can, at home (with excellent nursing care). Imagine how much more relief a nurturing, attentive, non-stressed nurse (with narcotics in hand) can bring to the patient and family, instead of some strong drug that simply prolongs the inevitable?

            •  If we thought about our pets (0+ / 0-)

              In general, I suspect most of us do a much better job of weighing cost of treatment, quality of life etc. for our pets than our system does for people.  We could probably learn some things about managing the cost of healthcare by looking at how people make decisions about their dogs.  My dog is fourteen and I adore him and I spend a good chunk of money on pain medicine for his  arthritis every month, but if he were to get cancer next week I'd probably spend what it takes to keep him comfortable and put him to sleep when his suffering becomes too great.

              And I hope if I were to get cancer in my eighties or nineties that someone would give me similar consideration...

      •  May not be acceptable, but it's reality (4+ / 0-)
        Recommended by:
        elfling, Fabian, Tamifah, AyLian

        Money is not infinite, and at some point, you've got to make tough choices.

        Decide the amount you want to spend, and then allocate it most efficiently.  

        You want to help the poor lady in Texas?  Fine, then increase the amount you spend.  

        But once you've hit a point where you have no more money to spend, tell me... what do you do?  

        Again, to be clear -- this is solely about cases of public spending.  Cases where we as a society need to allocate resources.

        •  this i understand (1+ / 0-)
          Recommended by:
          Fabian

          about money being a finite resource.

          i just think it's not humane to exclude certain people because of money considerations or something else.

          i do think you are onto something with prioritization of healthcare through public funding, i just don't like the idea of including people.

          in fact i think prioritizing things is the most responsible thing i've ever heard on the topic.

          right now the prioritization is how much money can be sucked out of you before you die, and that sucks.

          I'm kind of stalling for time here...They told me what to say. George W Bush, 03-21-2006 10:00 EST Press Conference

          by Tamifah on Fri Jul 21, 2006 at 05:06:27 AM PDT

          [ Parent ]

          •  End of life care (5+ / 0-)
            Recommended by:
            ohwilleke, Hlinko, elfling, Fabian, anais

            will, under any system, be one of the biggest ethical dilemmas.  People use up substantial medical resources in their last 2 years of life.  Clearly that's not an efficient use of resources, but who wants to refuse treatment to some poor old lady?

            The QALY metric seems as humane as any other.  There's a website around somewhere (Harvard School of Public Health, I think, though I haven't found it) listing a few hundred diseases and their associated QALY loss.  Check it out if you're interested in finding where your health conditions fit.

            •  I was forced to resuscitate a 90 year old lady (6+ / 0-)

              TWICE before she finally died after 17 days on life support.

              She was full of cancer, blind, demented, and had refused all healthcare up to the point of her respiratory arrest but her 12 children DEMANDED EVERYTHING and they got everything.

              The hospital was afraid to be assertive with them because it didn't want to get sued.

              I have never been so disgusted with the system; too cowardly to stand up for one patient's dignity against a litigious family..... but at least we provide care to anybody who needs it in addition to this extreme example.

              I don't understand why this is all so different from state to state. Maybe it is the Catholic hospital system I work in? We are not allowed to deny anybody care who needs it and in fact UNINSURED patients get more thorough workups in the hospital than INSURED patients because the insurance company denies our request to run tests.

              FUBAR.

          •  The difference is (0+ / 0-)

            I don't want to exclude people based on their personal funds.

            However, I am okay with excluding certain conditions. I am okay with a terminal patient not getting an expensive drug that may extend life only a month. If I have to choose between that and prenatal care, I'm going to spend my money on prenatal care.

            An organ transplant on a 90 year old man with cancer is generally not done. An organ transplant on a 50 year old can provide years of high quality life even though the two operations would cost the same.

            On the other hand, with cancer and certain other aggressive drugs/aggressive conditions, there is often value in getting them to people to boost our body of knowledge. Kind of the clinical trial ++ stage, where you've got the drug approved (for this condition or another) and it passed the trials, and so you think it helps, but you still need to know more about who it helps and why. There's value in spending money there even though it is quite expensive.

          •  The argument for universal health insurance (0+ / 0-)

            is that people shouldn't die simply because they are poor.  As an entitlement, the cost of universal healthcare is tied to the actual cost of doing that.

            But, there are limits.

            Most of the time, we have all the money we need to provide all the care people need, at least, that people urgently need.  The need for health care isn't infinite either, and realistically, to provide, at least, bare bones health insurance to everyone who doesn't have it right now is an $80 billion a year proposition.  Real money, but hardly beyond the means of our affluent nation.

            But, science is getting ahead of us at the end of life.  Part of the issue is resources.  There are only so many transplants available, but many people could be saved if we had more.  Transplants are the most obvious form of rationing and triage other than cost in our system right now.

            But, end of life care is immensely expensive and often doesn't produce huge results.  When a large percentage of all health care costs are going to the last month, the last six months, the last year of life, it is fair to question whether we have our priorities right.  For example, in cancer cases, it is typical to try the chemotherapy drugs most likely to work first, and to use chemotherapy drugs which are both extremely expensive (often because they are new and experimental) yet least likely to work last.  This is a rational treatment approach, but it means that you can be spending $5,000+ a month on drugs with a 5%-10% chance of extending your life for several months, when you get to the end.  We hang on for dear life, but sometimes that last miserable little bit can be damn expensive.

            "Those who can make you believe absurdities can make you commit atrocities" -- Voltaire

            by ohwilleke on Fri Jul 21, 2006 at 02:33:44 PM PDT

            [ Parent ]

      •  Should we assume that people want to be on (0+ / 0-)

        life support forever unless we hear otherwise, or should we assume that most people want to pull the plug unless we hear otherwise.

        Asked in advance, most people say, pull the plug.  The hard cases, like that one, come where there are no express statements of intent.  I've worked with a family and ICU people caring for a man who went between being in such pain that he was conscious but couldn't communicate, and being so drugged that he couldn't communicate, who was on life support.  He had no living will, but by family consensus the plug was pulled, which I have no doubt is what he would have wanted in that situation if he had thought about it and wrote it out when he could still communicate.

        ICU care for a month or two of a quality of life that is sometimes almost akin to torture, except when you are too drugged up to experience anything, could provide life saving medical care to dozens or hundreds of people.

        They aren't easy choices.  But, while this particular case may have gone over the line (I'm not familiar with it), default assumptions about what people would want, which are often contrary to people's real desires, can divert a huge chunk of medical resources from other situations with a much better prognosis.

        "Those who can make you believe absurdities can make you commit atrocities" -- Voltaire

        by ohwilleke on Fri Jul 21, 2006 at 02:24:05 PM PDT

        [ Parent ]

    •  Who decides on 'quality of life years'? (0+ / 0-)

      To make this truly fair we'd have to pick a committee at random (like a jury, I guess) and anonymize the cases by removing identifying names.

      Could we as emotional humans deal with this system? It still doesn't "seem" fair even though it's way more fair than "he who has no money, dies."

      •  i dont think.... (1+ / 0-)
        Recommended by:
        elfling

        that Hlinko meant you decide quality of life years on a case by case basis.  I think you make the decision for a particular condition.  Correct me if I'm wrong....

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