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View Diary: Paul Ryan: The Republican budget isn't unpopular, just misunderstood (110 comments)

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  •  Actually, David Brooks said something (0+ / 0-)

    that made me think in his column this morning.  (Yes, I know, some people will stop reading after I said the name "David Brooks.")

    But despite the fact that it came from a conservative, here's the point that is probably worth discussing about Medicare.  (And it's my paraphrase.)  

    Everybody -- on both sides -- agrees that Medicare costs are going to have to be reduced, some how, some way.  The dispute is over what Brooks called a "top down" v. a "bottom up" approach.  He called the Obama position -- a government panel to decide where to reduce costs -- a "top down rationing."  He called the Republican view, where consumers have more responsibility (and, as they get wealthier, more costs) a "bottom up" approach and tried to paint it as "consumer control."  

    But his point came across to me as this:  we're looking at two ways of rationing health care, and trying to decide, when we are talking about elderly patients (especially those at the end of life, who account for the vast majority of the costs) who gets what health care, and neither option is a good one.  Obama favors a government panel to decide where to "reduce costs" -- and that's clearly going to be painted as a panel rationing health care, because they are going to decide, as a matter of policy, that certain treatments or procedures are not going to be provided to certain patients in certain circumstances, when the chances of a positive outcome are greatly outweighed by the costs.  On the other hand, the Republican plan is essentially rationing by dollars -- those with more dollars can choose  to pay more for coverage, thereby getting better coverage and more health care.  "Rationing by dollars" is, of course, the way most things work in a capitalist society -- those with the most money get the most stuff.   The question worth debating is whether we should treat health care like any other good or service we purchase -- i.e., ration by dollars -- or whether should be some other method to decide who gets what health care (especially at the end of life, when the "return" on every health care dollar spent is lessened and become more and more tenuous).  And if we ration by "some other method," what should that method be.

    I think the debate is whether we "ration" by government panel, by wealth of the health care consumer, or by some combination of the two.  But clearly some change has to be made to Medicare over the long term -- President Obama has expressly recognized that.  

    I'd love to see an open debate on what I perceive to be a serious philosophical issue.  But I don't think either party is going to want to have an open and serious policy discussion about what is clearly an emotional topic, i.e., "health care for Grandma."  

    •  and this brooks article (0+ / 0-)

      is the latest trying to get things to stick

    •  I think (3+ / 0-)
      Recommended by:
      TofG, Headlight, Matt Z

      Brooks has it wrong. Again.
      The Commission that Obama is talking about is not going to be deciding case by case. They're going to look at ways to reduce costs, which can be done without affecting quality of care. Reducing re-admissions, making things more efficient, best practices, etc....  

      I just finished a book, The Check List Manifesto, by Atul Gawande, and it's amazing what can be done in healthcare to save costs by sharing information on best practices and putting them in to practice.

      Obama is also talking about increasing revenue, which the repubs are not. Repubs want to abolish medicare to give more money to their corporate masters, Obama is trying to save Medicare.

      There's a huge difference.

      "When a true genius appears in the world, you may know him by this sign, that the dunces are in a confederacy against him." - Jonathan Swift

      by American Zapatista on Wed May 11, 2011 at 01:40:13 PM PDT

      [ Parent ]

      •  "Best practices" (0+ / 0-)

        includes the decisions that certain treatments/procedures in certain circumstances have a low statistical probability of improving the patient's prognosis or increasing the quality of life.   Best practices includes empirical evidence about the statistical outcomes of certain treatments in certain situations.  

        In other words, if there is a $5000 treatment for a 90 year old patient that has a 50% chance of increasing his life by one year, is that a "best practices"?  What there is a 50% chance that his life is increased in time span, but a 75% chance that his quality of life is diminished after the treatment?  Someone has to decide if that fits into "best practices" or not.  What if the treatment is $100,000 and the possibility is 25%?  What if it $1 million, with a 10% possiblity?  And who makes the decision as to whether to spend $1 million on a 90 year old for something that has a 10% chance of extending his life by a certain period of time? If you would ask the 90 year old, you might get "spend whatever it takes to keep me alive as long as possible."  But a government panel of "best practices" may have determined that such a use of limited health care, with such a low probability of a successful outcome, is not "best practices."

        Take a middle-aged man who goes to the doctor with  mild pains in his chest.  After an examination, maybe an EKG, the doctor determines that it is 95% probability is it something other than heart related, but (like any doctor) cannot rule out a heart issue.  A stress test (expensive) could narrow the likelihood even more, maybe down to a 1 - 2% probability that it is heart related.  Who decides whether to spend that money for a stress test?  Those decisions have to be made some way.  

        In other words, "best practices" is a empirical, evidence based system of deciding what health care is appropriate for patients in specific circumstances.  It can have the effect of denying certain patients the health care they want because such health care is not "best practices."    

        "Best practices" is a method for deciding what health care is available in what situations.  No, decisions are not on a case-by-case basis. But it is applied to real patients in deciding what health care constitutes "best practices" in their situation.  

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