Having recently read the book 'The Hippocratic Myth' by M.Gregg Bloche, the striking subtext states "Why doctors are under pressure to ration care, practice politics and compromise their promise to heal". The author makes a convincing case for his thesis that the current political and economic climate and laws push doctors into juggling contradictory roles as caregivers and cost-cutters, in effect making a sort of mockery of the Hippocratic oath's injunction to 'enter every house only for the good of the patient'.
And yet, the costs of maintaining this kind of selfless, patient-centered care keep rising year after year, till it becomes all but unaffordable to the richest. At what point does it become necessary to bend this curve away from exclusivity towards inclusiveness? What are the costs we will incur, as a society, and can that cost be borne?
One anecdote in the book is about a daughter fighting to maintain the expensive drug regimen her 80+ year old mother needs to survive. "Who are these doctors to ration my mother's care?", to paraphrase her words as she argues that they cannot assume that her mother still has a foot in the grave, even without the drugs that she needs. The mother went on to a full recovery and more years of life, despite having had a life expectancy of about a week when the crisis occurred.
Another is a heartrending story of a low income pregnant mother whose cancer is missed in time because the physician attending didn't feel that a CT scan was warranted until it was too late and led to a cascade of events that crippled her. She might have been able to retain more faculties if it had been caught sooner.
The common thread was that of the doctor acting as a gatekeeper to the spending and clearly highlights an area that is now beginning to be discussed seriously, even as demagoguery about cutting back on Medicare, death panels and more are waved in front of voters to push them either towards the Democrats or Republicans.
The discussion has now started in earnest, as it well should, despite all the simplistic notions being flung around.
This NYT op-ed by Rita Redberg outlines many of the procedures that Medicare covers without questions asked, colonoscopies, prostate cancer screenings, drug-coated stents, all in patient populations that derive no significant benefit from having these procedures, and other inefficiencies in the payout model to private suppliers that currently run up a tab 75-150 billion dollars.
So how do we reconcile the outcry that is sure to be raised when there is a push to move from such procedures towards better preventive care and 'evidence-based' medicine based on appropriate epidemiological recommendations? We already see evidence of it in the backlash against the recommendation that women not at hereditary risk for breast cancer postpone mammograms till the age of 50, rather than starting them at age 40.
In the battle of emotion and personal anecdotes with nebulous abstract statistical analyses, it will always be the former that wins. It's so much easier to be dispassionate about some other larger amorphous group's health than one's own, or one's near and dear.
And yet, bend the curve we must, if the costs are to be contained. This means the unpleasant discussion about rationing care, trying to ensure that the broadest swath of people are covered by the limited budget, rather than trying to cover all treatments for all people.
Some experiments are already starting, like setting up ACOs (Accountable Care Organizations), but the recent evidence for their effectiveness isn't encouraging, suggesting relatively little savings and higher costs and inconveniences to providers than expected.
There were other ways suggested, as well, and provided for in the Affordable Health Care Act, but it remains to be seen whether these will help move the spiralling health care costs into a zone where rises are under control. Only then can a rational discussion ensue on how to dispense medical care to the larger public without making doctors violate the Hippocratic oath to provide the best care they can to the individual patient.
Accidental Blogger 
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