Wednesday, December 16, 2009

Spandex, Pounds, QALYs Rationing and Health Reform.

Years ago, the young and impressionable Disease Management Care Blog was struck by the appearance of a decidedly overweight person clad in tight spandex. An insightful friend remarked the appearance reminded him of 50 lbs. of potatoes in a 40 lb. bag. That summed things up pretty well.

And so it also is for Washington DC's attempt to offer a generous public insurance health benefit inside of a limited budget. Writing in this week's New England Journal of Medicine, Drs. Baiker and Chandra review the numbers and the politics of Uncomfortable Arithmetic - Whom to Cover versus What to Cover. While it could be argued that we have a) a moral obligation and/or b) a long term return on investment to be gained from covering 'everyone,' the authors point out that a) there is only so much Federal budget and b) covering everyone for everything is a poor use of money.

Given this uncomfortable reality, the authors argue that a more rational approach may be to ration low 'value' care by promoting the coverage of services that lead to a) higher numbers or b) higher quality years life gained at an attractive cost (a figure in Table 2 quotes $100,000 per year of additional high quality life expectancy).

If you're saying 'uh oh, QALYs again?' you're right. While these are simply mathematical expressions of the trade-offs we intuitively make when we're thinking about gains in life expectancy ('how much time, doc?') and the quality of those years (will I be able to get out of bed and walk?), the authors in this essay argue their use will become unavoidable. It may be rationing, but 'we will have to engage in the difficult discussions required to choose whom and what our public insurance programs should offer.'

The DMCB gets the argument but doubts this will gain much ballast outside the medical academosphere. There are two issues at play:

1) There doesn't appear to be much disagreement over the ultimate need to 'ration.' Rather, the authors' premise is that everyone agrees rationing should ultimately be a function of some enlightened and dispassionate public entity. Disagreeing with that assumption, a significant number of our citizens and policy experts would argue that rationing is better handled by an unfettered market. That perspective can be summed up by the proposals to regulate a stripped down minimum benefit designed to prevent bankruptcy and leave it up to insurers and providers to compete (across State lines) for the consumers' to 'buy up.' Vouchers could be used to help persons afford a plan that exceeds the minimum.

2) The current bevy of Congressional Committee Chair Barons are unlikely to countenance No. 1, above, so the DMCB offers up another reason to doubt that Drs. Baicker and Chandras' perspectives will ever see the light of day: voters don't understand the numeracy of researchy trade-offs in years, quality and dollars. What's more, Tea Party-like activists will quickly seize on their obtuseness to fashion even more rhetorical poison. The Committee Chairs may be insulated from this, but the rank and file members of Congress are looking at the 2010 elections with an increasinly grumpy electorate.

Most regular persons understand that more spandex is no substitute for losing weight or having too many potatoes for too little bag. While it may be a minority of voters who believe that it's up to individuals to figure out how to lose weight (arugment number 1), a majority are unlikely to have patience with the ratios of how much spandex is necessary to adequately contain a certain amount of girth and pounds.


Robert said...

As DMCB points out, many of us respond viscerally and negatively to any argument that rests on an improvement in QALYs since, most often, that metric is used for interventions that don't actually produce savings. Of course, when you start with the premise that there isn't enough money to go around the result of the analysis is self-fulfilling.

TurntoStoneBlog believes that we are too quick to accept the underlying premise and that by doing so, we avoid the even more difficult discussion of how to structure reform so that our system actually improves health AND reduces cost. As long as we are content to try and figure out how to produce more spandex, we'll never get to figuring out how to eliminate the need for spandex altogether.

Jaan Sidorov said...

Well said Robert. It's certainly not for lack of money that we seem to lack the political will to start all over again.