The Right Prescription

Facts Are Not Distortion

Government rationing of health care not only will happen -- it's already happening wherever government is involved.

By 8.14.09

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When it comes to evaluating the claims of Democrat party leadership and others about rationing and how to deal with grandma, I am guided by that great philosopher, Marx. That's Groucho, not Karl, who famously said: "Who do you believe, me or your eyes?"

The President and Democrats are promising, promising there are no "death panels" and that no one will "pull the plug on grandma."

I am not worried about death panels or plugs being pulled. I am worried about expanding government power about what to pay doctors, how to allocate care and telling me (and my doctor) something is ineffective, wasteful or unnecessary treatment.

That's government rationing. And it will happen.

Both House health and Senate bills require 20 million Americans to use Medicaid for health care coverage. That doubles the number of people on Medicaid while reducing Medicaid's already low reimbursement rate. Cutting Medicaid payments to doctors and hospitals to subsidize the health premiums of Generation X-ers who can afford to pay for healthcare but don't leads to rationing.

The White House and Democrats have the gall to respond there is rationing by private insurance companies. Yes, companies use what is known as comparative effectiveness research (CER) to decide what new technologies to pay for. By ignoring individual differences and information from the real world, CER studies wind up showing that there is no benefit to any new treatments most of the time.

There is also rationing by government agencies such as Medicaid and the VA system. Yes Medicare. All using CER.

Forget about grandma for a second. How about the kids?

Edith Andrews of Zanesville, Ohio, faced that problem last year when her twin girls, Sara and Samantha, were born prematurely nearly four years ago. Each weighed less than 3 pounds and needed a ventilator to breathe.

According to an article in the Cincinnati Enquirer: "To get care she had to take her infants to a Zanesville clinic or an emergency room, where they saw a different doctor every time, if they saw a doctor at all."

When Sara's lung collapsed, Edith couldn't find a Medicaid pediatrician to care for her. "Sarah's complications got worse and worse, and there was never a doctor around when I needed to talk to somebody." She finally found a doctor to take her daughters on as patients after a year of searching.

No rationing?

According to a 2007 Wall Street Journal article, Nicole Garrett's three teen-age children lost their private coverage and she enrolled them in Michigan's managed-care Medicaid program.

When Nicole's 16-year-old daughter, Jada, needed to see a rheumatologist, the one listed in her managed-care Medicaid plan's network would not see her. Nicole notes, "When we had real insurance, we could call and come in at the drop of a hat."

Last week Sen. Chris Dodd was rushed into surgery less than two weeks after his cancer diagnosis. Jada's wait just for an appointment was a bit longer: The wait to get into a public clinic was more than three months.

By the time she found a Medicaid-approved rheumatologist in a nearby county to take her in months later, Jada's debilitating pain had caused her to miss several weeks of school.

CER is already being used in Medicare.

Virtual colonoscopy using computed tomography (CT) will not be covered by Medicare. That eliminates a treatment option for patients reluctant to get screening.

Two years ago, Medicare use CER to eliminate differences in the amount of blood-boosting drugs available to elderly cancer patients. The result? More seniors required more transfusions instead of a one-time shot of the drug to maintain healthy red blood cell levels. Meanwhile, the one size fits all payment approach discriminates against blacks who often need more ESA to avoid anemia while receiving chemotherapy or dialysis.

Congress and the President pushed for $1.1 billion of comparative effectiveness studies mostly doled out by the Agency for Healthcare Research and Quality (AHRQ). The talking points are it's all about "eliminating unnecessary procedures and hospitalizations."

Starting with Medicare.

America's Health Insurance Plans, the insurance lobby, has said (pdf), "[Medicare] should be given explicit authority by Congress to use available data on comparative effectiveness and cost-effectiveness in determining its coverage policies. Similarly, [Medicare] should be empowered to set its reimbursement rates for new technologies more in alignment with the added (or marginal) value of a new technology over established alternatives….and…..include incentives for providers who practice in accordance with such guidelines."

Under the House bill Medicare would tell private companies what new drugs to add its drug benefit based on AHRQ-sponsored CER. Not that it needs the coaxing. In the October 2007 Managed Care Magazine, Kenneth Kizer, MD, MPH, former CEO of the National Quality Forum, clocked the time it took for private plans to respond to Medicare policy changes at two nanoseconds.

With AHRQ channeling both government and private plan decisions, buckle up for time travel.

In 2007, AHRQ told Congress and a federal council empowered to insure AHRQ recommendations are adopted that it would focus on areas of greatest "total costs associated with a condition, procedure, treatment, or technology…whether due to the number of people needing care, the unit cost of care, or indirect costs." And it would examine how to control costs where the money is now spent: seniors with chronic illnesses such as cancer and end of life care, special needs kids like Jada and Sara and low birthweight infants fighting to survive.

AHRQ is also developing tools to deliver this information straight into the computers of the health plans and doctors of America. Alongside all that billing data of course.

The Jadas and Saras of America will feel the effect immediately. Those who are sick at the beginning and end of life will wait longer for fewer advances. Death panels and pulling plugs? No. Rationing that limits our freedom to choose and seek out the best care possible? Believe your eyes, not me.

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About the Author
Robert M. Goldberg is vice president of the Center for Medicine in the Public Interest and founder of Hands Off My H ealth, a grass roots health care empowerment network. His is new book, Tabloid Medicine: How the Internet is Being Used To Hijack Medical Science For Fear and Profit, was published last month by Kaplan.