Saturday, December 29, 2007

Medical Ethics and Health Care Costs

The struggle between rational thinking about health care costs and fantasy about a Lala land with no financial limits continues.

Yesterday’s New York Times reported that Aetna is planning to restrict coverage for the anesthetic propofol to high risk cases as of April 1, 2008.

Propofol acts rapidly. It allows people undergoing colonoscopy to be relaxed and sedated more speedily than the alternatives. And, after the procedure, to wake up more quickly as well. Colonoscopists like propofol for the depth of anesthesia it gives and the fact that it allows them to complete the procedure in less time, which increases productivity.

But propofol can depress respiration and even cause respiratory arrest. Many believe that handling propofol safely requires an anesthesiologist to be part of the colonoscopy process. This drives the cost of the test up substantially.

The article is revealing about the social learning curve U.S. society must progress on to get a grip on health care costs. Dr. Douglas Rex, a colonoscopy expert at Indiana University, gets it right: “It’s perfectly appropriate to say this doesn’t look like a good place to spend health care dollars.” Even if you disagree with Rex’s conclusion, you have to acknowledge that he is right to think about value and opportunity cost. It isn’t harmful to use propofol and have an anesthetist present – but is it worth it, compared to other uses of the same money? This would be a productive debate.

In contrast, the article quotes “many doctors” who “say that the freedom to choose the treatments used is an important principle to preserve no matter what the cost to insurers…” This is vintage Lala land talk. The “many doctors” who indulge in this form of magical thinking invite us to believe that insurance companies are trees that grow money. There is no recognition that insurance funds come from employers, who take it out of the wages that would otherwise go to employees, or from taxpayers, whose money could be used for other priorities.

In growing up we learn self control through repetitive encounters with reality. We can spend our allowance on candy bars now, or save it and get a basketball later. Sadly, we can’t do both.

As a society we need to grow up with regard to health care. I don’t know enough to have a strong position on how valuable it is to use propofol routinely for colonoscopy, as apparently happens in New York City, where 77% of the Aetna enrollees receive it, compared to 10% elsewhere. Maybe New York gets it right, and spending our money on propofol (and the like) is better than providing more home care or raising wages.

Our society needs to have debates like this one again and again. We need to school ourselves in recognizing limits and deliberating about value. If we can teach our children about candy bars versus basketballs, we can teach ourselves to think about what matters most to us in health care and what we will choose to forgo.

Physicians who tell their patients and the public that “the freedom to choose the treatments used is an important principle to preserve no matter what the cost to insurers” are like parents who bring up spoiled kids. The medical profession has to move beyond this kind of magical thinking.

Let’s get more real about health care costs and value in 2008!

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