Friday, December 09, 2005

NHS may not treat smokers, drinkers or obese

Ah, the wonders of socialized medicine ... and a really, really, really slippery slope here.

NHS may not treat smokers, drinkers or obese
By Celia Hall, Medical Editor
The Telegraph
(Filed: 09/12/2005)

People who are grossly overweight, who smoke heavily or drink excessively could be denied surgery or drugs following a decision by a Government agency yesterday.

The National Institute for Health and Clinical Excellence (Nice) which advises on the clinical and cost effectiveness of treatments for the NHS, said that in some cases the "self-inflicted" nature of an illness should be taken into account.

But the report bars any discrimination against patients on grounds of age alone.

Nice stressed that people should not be discriminated against by doctors simply because they smoked or were overweight. Its ruling should apply only if the treatment was likely to be less effective, or not work because of an unhealthy habit.

The agency also insisted that its decision was not an edict for the whole NHS but guidance for its own appraisal committees when reaching judgments on new drugs or procedures.

But the effect is likely to be the same.

Nice is a powerful body and the cause of much controversy. It is seen by some as a new way of rationing NHS treatment.

Across the country primary care trusts regularly wait for many months for a Nice decision before agreeing to fund a new treatment.

One group of primary care trusts is ahead of Nice. Last month three PCTs in east Suffolk decided that obese people would not be entitled to have hip or knee replacements unless they lost weight.

The group said the risks of operating on them were greater, the surgery may be less successful and the joints would wear out sooner.

It was acknowledged that the decision would also save money.

I'll bet it will.

-- SS


Anonymous said...

Even if you feel the NHS goes too far,what would happen in this country if they ever perfect lung transplants. Would we really pay for every smoker who developed COPD,to get a transplant? It certainly would finally spark a real debate.

S. Brownlee said...

Here's a real example, a real person I know: a liver transplant patient who needed a new liver because he drank the first one into oblivion. He's a year out from his transplant and still drinking like a fish, while lying like a rug about it to his doctor. It won't be long before he burns through this liver, too.

Livers being in short supply, somebody else lost out on a chance of getting the organ that was transplanted into this guy, and I wonder how the family of that liver patient who could have gotten that organ would feel if they knew what he was doing to it.

We don't think of health care as a zero sum game, but it is. Somebody's gain is usually somebody else's loss, because even in this country, where we spend more than twice per capita what the NHS spends, we don't have enough of everything to give to everybody. The liver we give to an alcoholic who can't be bothered to take care of the incredible gift he's been given is a liver we can't give to a hep C patient who who wouldn't abuse his transplanted organ. And the money we spend on, say, PSA screening and the downstream consequences of screening, which brings down the mortality rate from prostate cancer only infinitisimally if at all, is money we don't spend on making alcohol rehab widely available to people like this poor, uneducated alcoholic who is wasting a perfectly good liver.

The idea that the only tradeoffs in medicine are in systems that are socialized is simply wrong. We make tradeoffs all the time; they just aren't rational or out in the open.

Roy M. Poses MD said...

One issue is whether the trade-offs are made at the individual patient level by physicians and patients, or in a much more ham-handed way at the government level.
In this case, if the physician thought it was very likely that the patient would resume drinking, he or she could have decided not to suggest a transplant for the very good reason that a patient who was likely to continue to drink heavily would likely not get enough benefit from the transplant to be worth the risks of doing it. So this particular problem could have been prevented, in theory, by good decision making at the individual patient level.
How would you craft a guideline at the government level that would have prevented this transplant, but would not prevent better justified ones? It's pretty hard, other than to ask the physician to use the best possible judgment.
Furthermore, beware the transplant example. At the present state of technology, transplants really are a zero sum game. But much of health care really isn't.

s.brownlee said...

OK, so transplants were too easy an example.

My real point is only that while the NHS makes specific, transparent, and one hopes rational decisions about tradeoffs, in this country we make them on a the basis of what is most profitable. Here's just one example: Medicare and most private insurance will pay and pay and pay for angioplasties and stents, regardless of the fact that many if not a majority of the time these procedures are performed when medical management would do just as well, for less money. We are spending a heck of a lot of money that we might better spend in myriad other ways, ways that would do far greater good for far more people. Prenatal care for all women, no matter how poor, for instance. Drug addiction treatment. Decent lunches in schools, for heaven's sake. But nobody makes big money on prenatal care, good food for children, or drug addicts, and in our system, we tend to pay for interventions that have the highest profit margins, not the greatest return in health.

Our healthcare really is also an economic zero sum game. The 17 percent of GDP we spend on healthcare is money that could probably be better spent in other sectors of the economy. Sure, healthcare keeps a lot of people at work: nurses, janitors, drug reps, doctors, adminstrators, device salesmen, surgical mask makers . . . . But the marginal return on our investment in this industry is getting smaller and smaller in terms of healthcare's product -- which is health. We spend more than anybody else in the developed world by a long shot, but we don't get as much health out of every dollar we spend. On top of that, our healthcare costs make all our goods less competitive in the global market.

Think of the jobs that are not created in other industries because we are so busy paying for marginally useful healthcare. But we are also missing out on potential health gains because we are so busy paying for angioplasties and stents, rather than paying primary care physicians, or even nurse practitioners, to help their patients learn how to exercise more and eat less, just to name one example of the kinds of interventions that would improve health more(and maybe for far less money)than interventional cardiology. Paying for defibrillators and stents and lots of time in the ICU near the end of life might seem like a kind and generous thing to do, but it is at the expense of other measures we could be taking that would contribute far more to the general health of both the economy and American citizens. THe NHS has its faults (though why everybody persists in pretending the NHS and Canada are the only two models out there is beyond me), but they are a lot further away from breaking the banks of their economies than our system. Our system, by contrast, is not only going to suck up all our money, it is leaving our population not as healthy as it could be, and therefore not as productive, while at the same time making our goods too expensive for other people to buy because we are so busy paying for marginally effective healthcare. Talk about a zero sum game.

Roy M. Poses MD said...

OK, let's use the angioplasty and stent example. There are really two questions here for the "system." Under what circumstances do you pay for them? And then, how much do you pay?
One major peculiarity in the US is that neither CMS, which answers these questions for Medicare patients, nor managed care, which answers them for most employed, insured patients, seem to think at all about the second question. They both pay a whole lot.
The pie would be a lot bigger if we didn't spend so gosh darn much money on each angioplasty and stent procedure.
Yet all the debate is about the first question, who should get these procedures, rather than the second, how much should you pay for each.
Why don't we consider the second question? And isn't that second order question the $64 billion dollar one?

s. brownlee said...

Why don't we consider the second question? Ask the medical guild, or the AMA. One of its primary concerns for the last century has been preserving physician autonomy and incomes. The AMA opposed Medicare on the slogan that it was "socialized" medicine, which had a nice anti-totalitarian ring to it, but the real reason was that fees might be regulated. Local medical societies opposed public VD clinics in the 30s, because they were cheap competition. As an organized profession, medicine has been very effective at persuading Americans that phyisicians must be allowed to make as much money as they could, in any way they saw fit, or the public's health would suffer.

The most visible result of the success of the AMA's PR is that most Americans think doctors should be highly paid. Specialists certainly think they deserve to be richly rewarded. Of course, I doubt most Americans know just how well paid many specialists really are. Better than most lawyers, that's for sure.

While it is tempting to suggest when one is not a cardiologist or a radiologist or any of the other big-money specialists(and I do mean big) that the answer to our high healthcare costs is trimming the incomes of specialists, let's think about how we would do it. We've already discovered during the rise of corporate managed care that cutting reimbursement per procedure or office visit makes only a temporary dent in rising costs. Eventually hospitals and doctors figure out ways to increase volume to make up for lost income. That has been true for primary care as well as specialists -- though the reimbursments are much smaller for primary care. (And I'm pretty sure that most medicine is not managed care any more -- it's back to fee for service, albeit diminished fees. The payers have given up on capitation for the most part).

So there are two ways to bring down costs: One way is to make everybody work in a salaried, group practice. (I think this is a great idea, but I'm sure there is screaming going on at this very moment as dozens of eyeballs have taken in that sentence.) The alternative is to find another way to bring down the rate of unwarranted or unwanted office visits, tests, and procedures.

I include the term "unwanted" because in so much of medicine its not yet possible to say with much certainty what is appropriate and what isn't. That means that patients should be thoroughly informed about the potential risks and benefits so they can decide if they want a PSA test or endarterectomy or stent or any of the other procedures and tests that are now being used in the absense of good evidence they will benefit that patient. Every study of shared decision making, where patients really understand uncertainty and tradeoffs, shows that patients are less willing to undergo procedures and tests than their physicians think they are. In other words, demand goes down when quality information goes up.

Finding ways to reduce unwarranted care short of making everybody work in a salaried group practice is probably a topic for another discussion.

s. brownlee said...

I knew I was forgetting a very big piece of the puzzle. We have also been bamboozled into believing that we should pay top dollar for new devices and drugs. One would think there would be price competition when there are two stent manufacturers, or two makers of statins, but it's amazing how much we are willing to pay for these things, even when competitors exist and when there is poor evidence for their effectiveness. I can't quite figure out that puzzle. Why haven't payers been able to force down the price of devices and drugs substantially?

David Cutler the Harvard health economist, would argue that we ought to pay high prices because that's what keeps innovators coming up with so many great new technologies. My question is, who says their innovations are so great? There is often only scant evidence for effectiveness, much less superiority over existing technologies, by the time new drugs and devices become entrenched in the market.

Roy M. Poses MD said...

I think Shannon Brownlee's last post is getting close to the central question. Sure, some specialists and sub-specialists make quite a lot of money doing procedures and operations, maybe more than some lawyers. (But if you look at how much top lawyers bill an hour, hardly more than all lawyers.) But physicians' fees are actually a small piece of health care costs, and most physicians don't make anywhere near that much. (Typical pay for primary care physicians and most "cogntive" specialists, i.e., physicians who don't do procedures, is similar to that of airline pilots.) But it's interesting that nearly all public discussion on health care costs focusses on physicians' fees, and then nearly all efforts to control costs are either cutting physicians' fees across the board, which hurts primary care and "cognitive" physicians the most, or cutting utilization, e.g., numbers of patients' visits. Note for example that Medicare is once again threatening to cut physician reimbursement across the board, but not hospital reimubursement, and part D Medicare is not allowed by law to even negotiate drug prices. But the constant talk about greedy physicians does seem to foreclose talk about greedy pharma and device companies, greedy hospitals, greedy managed care companies, etc., etc., etc.
The big issue are the costs other than physicians' fees, particularly those drugs and devices, hospitals, and of all the third, fourth, fifth, and sixth parties (a la J D Kleinke). Take a look at this older post on Health Care Renewal for some discussion:

s. brownlee said...

At the risk of sounding like I's physician bashing, physician fees are not such a small part of our healthcare costs: they account for about 20 percent -- around $340 billion -- of the total bill. With 800,000 doctors, that's around $400,000+ per doctor, and I would imagine that most of the primary care physicians on this list aren't making anything close to that. (That's more than the average lawyer, by the way.)

Hospital bills are, of course, the other biggie. Device costs are buried in the hospital portion, and I'm speaking here not just about implantable defibrillators and artificial hips and artificial arteries, but also about the really big ticket devices like spiral CT scanners. Drugs account for a small percentage of the total, but the fastest rising at the moment (thank you Congress and Medicare Part D for ensuring that drug prices won't be going down any time soon).

Roy is absolutely right that squeezing physician fees is not the answer -- in part because as he points out, the cognitive work of primary care doctors always gets squeezed the most. But squeezing fees also doesn't work for the reason I mentioned earlier: when fees go down, volume just goes up. But it is never the volume of care that is evidence based, and that patients really need -- because payers don't reward hospitals and physicians for that kind of care; they reward disproportionately for procedures.

Roy M. Poses MD said...

Just a reminder - for a doctor working in an office, just like for any small business, gross recipts do not equal net income. Assuming the figures above are accurate, if the average doctor's office has receipts of $400,000 per year per doctor, assume more than half of that will go to running the office. This would yield an average income of perhaps $150,000 -- hardly chicken-feed, but I would guess, similar to what other professionals make. Note also that office overhead has been going up about twice as fast as reimbursement rates.

Anonymous said...

i think that smokers should get treatment on the nhs as long as they get patches or chewing gum to help them stop smoking before the treatment (operation) is performed.