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Healthcare must be rationed, including mammograms, doctor says

November 25, 2009 |  2:01 pm

Yet another doctor has come out with a critique of the new breast cancer screening guidelines released last week by the U.S. Preventive Services Task Force.

Mammo Writing in the New England Journal of Medicine, Dr. Robert Truog of Harvard Medical School says routine screening for women between age 39 and 49 has cut the risk of death from breast cancer by 15%: “Clearly, screening mammography does offer an identifiable survival benefit to women in this age group.”

But he doesn’t necessarily oppose the task force’s final result. Though the expert group explicitly left cost out of the equation, Americans as a whole can’t afford the same luxury, Truog writes.

“Screening mammography for women in their 40s is clearly effective. The problem is that the benefit is tiny and expensive. … Statistician Donald Berry has calculated that for a woman in her 40s, a decade’s worth of mammograms would increase her lifespan by an average of 5 days – and this survival advantage would be lost if she rode a bicycle for 15 hours without a helmet (or 50 hours with a helmet).”

The Obama administration – supposed backer of cost-cutting “death panels” – doesn’t want to invoke what Truog calls the “R” word, and neither do Americans. But healthcare reform will never succeed if we don’t own up to the reality of rationing, he writes.

“Rationing is not a four-letter word. No health care system in the world, including our own, is free from the necessity of rationing. As long as a health care system has anything less than an infinite budget, there is a need to decide which types of health care will be funded and which will not.”

Seen in this light, the vitriol directed at the task force is understandable, but misguided, Truog writes:

“The choice is not between health care rationing and some undefined alternative, since there is no alternative. Rather, the choice concerns what principles we will use to ration health care. In the United States, we have traditionally rationed health care in the same way we ration expensive cars: those who can afford to pay for them are those who can have them. The alternative currently being considered in health care reform would involve a shift to other principles, such as those rooted in considerations of fairness, efficiency, and efficacy.”

-- Karen Kaplan

Photo: Are mammograms for women in their 40s with an average risk of breast cancer the best use for limited healthcare dollars? Credit: Rui Vieira/AP Wire

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Comments (1)

If we do more illness prevention we will free up money. For example, having adequate vitamin D levels cuts breast cancer 50%. Kids and adults need to exercise, eat well. Perhaps with more HMO's insurances could be allowed to purchase at least part of a MRI so they don't hemorrhage money for scans. Similarly perhaps insurers could own labs so they pay for actual costs of the lab, not the inflated cost (vit D is 1-6 dollars to do, and costs $60 to $278 at labs in Oregon). The fewer middle people, the more actual health care can happen. There should be a cap on profits of companies--if exceeded it should not be returned to doctors for withholding tests, but rather given back to consumers, giving consumers the incentive to not get too many tests. Let's end drug advertisements, because we pay for them. Paperwork ideally should actually pertain to patient care, and not so much having pretty data that is easy to obtain (ie have easy patients, have them all improve or leave your practice if they don't because they aren't trying hard enough etceteras). And finally, we should make 95% of clinical decisions based on what the patient says, which means 7 minute appointments aren't going to work. Maybe 12 minutes would allow you to obtain the correct information to solve the problem correctly the first time and not do in 3 visits what could have taken 1 visit. (At least in Salem Oregon that occasionally happens). Let patients evaluate how they think their care is, and have that be a key indicator.
Consider a whole life insurance policy instead of a health insurance policy. The premiums are similar for State workers up here in Oregon. However for the first time, it would actually pay your insurer to keep you alive paying premiums. Let's face it--if you have a chronic expensive illness that will kill you now or later, it's cheaper to let you go now. However, the incentive to keep you going would be there with a whole life plan where the longer you live, the more you give. Because nursing homes take a big chunk of the budget now and pay poor wages in most of the country, their profits should be capped as well and the need for them reduced. Money could be shifted from nursing homes to physical therapy to prevent falls, vitamin levels to prevent dementia etceteras. Towards the end of your life, the less time you need a nursing home because of prevention should be a financial reward for your insurance company that helped you stay healthier. And that's where the insurers big profits should be--make them want you to do really well, and really for the first time let them help with that, and not just have to react to calamities. Let many organizations not currently allowed to buy insurance, buy insurance to drive prices down with competition for their money (which could have a more robust tax benefit for businesses that encourage breaks, happy workplaces, exercise and have good food). When many groups lost the ability legally to obtain insurance, it seems med costs escalated. Just like we (doctors) believe malpractice lawyers should have profits capped, so should we, and also drug companies. Incidentally to all you programmers: you only have one brain on a computer, and so do the docs you are designing systems for. So plan for docs to talk with patients and spend very little time with you system since the patient matters most. And everyone needs to be frugal so they have money to take care of themselves as well as possible. From: An Oregon Curmudgeon


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