NICE QALY you got there
posted at 8:40 am on August 19, 2009 by Pundette
Did you know that the life of an adolescent is more valuable than the life of a baby or an old person? Hey, it’s supported by empirical surveys. But I’m getting ahead of myself.
Just so there’s no confusion, may I repeat what I said the other day: the “death panels” have not been dropped from any of the bills. Rationing boards, such as NICE in the UK, are intrinsic to and inextricable from a public plan. What was dropped by the Senate finance committee was the end-of-life counseling provision, thanks in part to Sarah Palin’s “death panel” statement.
A federal health board concerned with an issue essential to rationing is already in place. It’s the Federal Coordinating Council for Comparative Effectiveness Research:
“Comparative effectiveness research can improve care for all Americans and is an important element of President Obama’s health reform plan,” said HHS Spokeswoman Jenny Backus. [. . .]
Comparative effectiveness research provides information on the relative strengths and weakness of various medical interventions. Such research will give clinicians and patients valid information to make decisions that will improve the performance of the U.S. health care system [. . .]
The Council will not recommend clinical guidelines for payment, coverage or treatment. The Council will consider the needs of populations served by federal programs and opportunities to build and expand on current investments and priorities. It will also provide input on priorities for the $400 million fund in the Recovery Act that the Secretary will allocate to advance this type of research.
Comparative effectiveness data, obviously useful in helping patients and doctors make decisions on treatments, is a basic building block for rationing formulas. Let’s not forget Tom Daschle, Obama’s first choice for HHS and author of Critical: What We Can Do About the Health-Care Crisis. His prescriptions for healthcare reform are heavy on comparative effectiveness:
Perhaps the most striking part of Daschle’s plan is his call to create a Federal Health Board, modeled on the Federal Reserve Board that manages monetary policy. The basic idea is to create an institution, run by experts, that answers to the government but is “largely insulated from the politics and passions of the moment,” he writes.“Like monetary policy, health-care policy shouldn’t be subject to the whims of subcommittee chairmen and special interests,” Daschle continues.
The board wouldn’t regulate the private insurance market, but it would have power over federal health-care programs, including Medicare and Medicaid, whose decisions are often followed by private insurers. It would also set the terms for private insurers who wanted to participate in the federal employees’ insurance pool.
Perhaps most importantly, the Board would assess the effectiveness and costs of various treatments.
He stops short of saying the U.S. should have a U.K.-style, hard-and-fast rule on cost-effectiveness. But he does say the U.S. “won’t be able to make a significant dent in health-care spending without getting into the nitty-gritty of which treatments are the most clinically valuable and cost effective.”
It just so happened that Daschle’s tax problems exceeded the acceptable Obama administration limit. But his goals for “reform” are wholly consistent with the Obama agenda.
In order to understand how rationing will work under government-run healthcare, please read Would Roger Ebert Go Before Obama’s Death Panels? by Donald Douglas. He links to articles which explain the formulas used by rationing boards when allocating treatments. Factors include the patient’s age and state of health and the cost of the treatment. From Martin Feldstein:
In the British national health service, a government agency approves only those expensive treatments that add at least one Quality Adjusted Life Year (QALY) per £30,000 (about $49,685) of additional health-care spending. If a treatment costs more per QALY, the health service will not pay for it. The existence of such a program in the United States would not only deny lifesaving care but would also cast a pall over medical researchers who would fear that government experts might reject their discoveries as “too expensive.”
Dr. Ezekiel Emanuel doesn’t actually advocate the QALY system, but prefers the “complete lives system,” which gives resources to the young before the old, since the old have already been young. But note that adolescents take priority over babies:
Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritising adolescents and young adults over infants. Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments. Similarly, adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfilment requires a complete life. As the legal philosopher Ronald Dworkin argues, “It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does”; this argument is supported by empirical surveys. [emphasis added]
Insert your own outrage here. Funny, isn’t it, that the lives that are deemed most worth investing in, the adolescent through the middle-aged, are those that are physically strongest and most able to fight for their own survival.
Betsy McCaughey quotes more from Emanuel on why some young lives are worth saving more than old ones:
He explicitly defends discrimination against older patients: “Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years” (Lancet, Jan. 31).
How would you like to be the patient of a physician like Dr. E?
Dick Morris describes what he calls “de facto” rationing:
While the conclusions of this board are not specifically imposed on HMOs and health care providers by the legislation, their recommendations will, inevitably, set the standard of care and the protocols that should and will be followed throughout the system. Otherwise, why collect the data at such great cost and effort? Individual public or private insurance companies, and their HMOs, will use these data to allow or deny care to the elderly, a de facto rationing system.
Does a hip replacement cost $100,000? A 75-year-old diabetic with a heart condition may only have three more quality adjusted years. At $33,333 per year, the price is too steep and the surgery would likely be disallowed. But a 50-year-old who is otherwise healthy, may have 25 years of quality life ahead of him, and, at $4,000 per year, the surgery makes sense.
These assessments diminish the importance of the remaining lives of the elderly and condemn them to infirmity, pain and an earlier death than would otherwise be their fate.
To the extent that any of these steps that curtail care for the elderly lead to an earlier demise, end-of-life counseling will be necessary. While no panel will specifically pronounce a sentence of death on an old person, doctors, hospitals, HMOs and the Federal Health Board will all be forced to participate in decisions to deny adequate care that will amount to the same thing.