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Medical Forum / General / General / July 2005sometimes we have to tell the dying "no"
Drug costs count: Sometimes we have to tell the dying "no" By ANDRE PICARD Thursday, July 21, 2005 Page A13 They are heart-wrenching tales: The young mother struck down in her prime by breast cancer, and cruelly denied a miracle drug; the brilliant lawyer diagnosed with colon cancer but unable to access the medicine deemed his best hope for survival. The bad guys in these stories are vile bureaucrats and their heartless political bosses, who deny cancer patients access to breakthrough drugs to save a few lousy bucks. If only it were so simple. The reality: Drug costs (particularly cancer drugs) are skyrocketing, and the benefits of new drugs are often marginal. Despite the pharmaceutical company bumph -- and what patients themselves desperately want to believe -- miracles are few and far between, and cures are even more elusive. As such, deciding which drugs will be used, and which will be covered by public health and drug plans, is a difficult proposition. It requires asking questions for which there are no easy answers: Should patients be guaranteed access to drugs regardless of cost? Should physicians consider a drug's cost when prescribing it? At what point is a drug deemed inadequate, or too expensive? Of course, if your child, your mother, your spouse is suffering, is dying, money is no object. No one can fathom the notion that treating their loved one is "not worth it," no matter how fleeting the hope. But we cannot allow ourselves to make important public-policy decisions based on pity, or raw emotion. Nor can publicly funded drug plans (or private ones, for that matter) allow themselves to automatically reimburse or subsidize every new drug. Determining if and when drugs should be covered must be done in a dispassionate, rational manner. In the emotion-free world of health economics, scientists base their recommendations on the cost of extending a person's life by one year. This measure is called a QALY, or quality-adjusted life year. It is generally accepted that an intervention -- be it a drug, surgery or prevention program -- with a cost per QALY of less than $50,000 is deemed cost-effective. Yet, determining the cost per QALY is rarely straightforward. Clinical trials to determine the effectiveness of drugs are done in ideal situations, with specific groups of patients. Real world results are hardly ever as good. And what is a good result, anyhow? Take the colon-cancer drug Avastin. In clinical trials, it extended life by an average of five months -- to 20.3 months from 15.6 months. Is that good enough? At $55,000 a year, is it worth the cost? Or could we get more bang for our health-care dollars by spending that money on screening for colorectal cancer, or on health promotion campaigns? Doctors hate the idea that a committee of pharmaco-economists could influence their prescribing decisions. But rhetoric about independence and "putting patients first" should not obscure the need for checks and balances. There is currently no incentive for a physician not to prescribe liberally -- and plenty of inducements from pharmaceutical reps encouraging them to do so. Drug companies are in the business of selling hope -- sometimes at exorbitant prices. When Taxol was introduced in the market in 1992, the $4,000 annual cost was considered outrageous. Now we have Herceptin (breast cancer) at $50,000, and Erbitux, another colon-cancer drug, at $100,000. Can the $1-million prescription drug be far away? When governments create mechanisms to determine if 'miracle' drugs are living up to their promise, and whether they are a worthwhile investment -- such as the formulary committees that exists in each province and the Common Drug Review -- they are not being cruel and obstructionist. On the contrary, they are being responsible administrators. If there is a shortcoming in our current approach, however, it is a lack of transparency, a failure to explain how decisions are made and why specific drugs are not covered. Patients and their families deserve explanations, prompt decisions and consistent judgments. The bottom line is that health dollars are not unlimited. We already spend $16-billion a year on prescription drugs. Sometimes we have to say "no." Our inflated expectations and overpoliticization of health-care administration make that difficult, doubly so when the media give blanket coverage to sad stories, often without the necessary context -- in particular, a hard look at the real costs and benefits of drugs touted as miracles. Paying too much for drugs, and paying for drugs that provide only a marginal benefit, serves no one. It may be politically expedient but will have painful long-term consequences for all of us, diverting precious health dollars from more cost-effective initiatives. fairuse http://www.theglobeandmail.com/servlet/ArticleNews/TPStory/LAC/20050721/HPICARD2 1/Health/Idx >Drug costs count: Sometimes we have to tell the dying "no" > [quoted text clipped - 16 lines] >desperately want to believe -- miracles are few and far between, and >cures are even more elusive. <cheap rhetorical shot> Much copyright infringed stuff snipped.</cheap rhetorical shot> Actually this story pretty much frames the problem with the debate on health care in the US. Unlike Canada, Great Britain and most other countries with universal coverage, we have not yet been able to wrestle to the ground what constitutes 'universal' coverage. Do we or do we not transplant every long-term alcoholic with liver disease? Do we let nature take its course if someone can't/won't/don't follow medication requirements for HIV drugs? Do we chemo everyone over 75? This would indicate that we expect do everything for everybody. -- "No nation would be so dumb as to say that we all want to go one point, we just don't know how to get there. What we are finding is some want to go to San Diego, some to Seattle. We are ashamed to admit this so we pretend we all want to go to San Francisco." Uwe Reinhardt on the health care debate. > >Drug costs count: Sometimes we have to tell the dying "no" > > [quoted text clipped - 30 lines] > This would indicate that we expect do everything for > everybody. Andre is hittin' it. Doncha think? But your argument really doens't hold water. What about the guy (or gal) who sits at the computer too long, and follows that with several more hours watching television. Are we going to continue pay for their self-induced cardiovascular disease? See....? > -- > "No nation would be so dumb as to say that we all want to go one point, > we just don't know how to get there. What we are finding is some want to go to > San Diego, some to Seattle. We are ashamed to admit this so we > pretend we all want to go to San Francisco." > Uwe Reinhardt on the health care debate. > Are we going to continue pay for their > self-induced cardiovascular disease? How about breast cancer? Is that self-induced? It does have lifestyle factors. >> Are we going to continue pay for their >> self-induced cardiovascular disease? > >How about breast cancer? Is that self-induced? It does have lifestyle >factors. All good questions. With no US answers as of yet. -- "No nation would be so dumb as to say that we all want to go one point, we just don't know how to get there. What we are finding is some want to go to San Diego, some to Seattle. We are ashamed to admit this so we pretend we all want to go to San Francisco." Uwe Reinhardt on the health care debate. Well there ya go. Shootin' holes all over Ullman's theorizing. zee >> Are we going to continue pay for their >> self-induced cardiovascular disease? > > How about breast cancer? Is that self-induced? It does have lifestyle > factors. They used to say that about TB. They said that TB victims were melancholy. I guess they were. Once the real cause of disease is found, no one pays any attention to fake lifestyle charges. > Actually this story pretty much frames the problem with the >debate on health care in the US. Unlike Canada, Great Britain and [quoted text clipped - 6 lines] > This would indicate that we expect do everything for >everybody. There are always cases of limited resources. You can't transplant a liver into everyone who needs one because there aren't enough livers available, but how do you decide who gets the organ? Is it the person who can pay for it, or the one who can get the most years of useful life out of it? So there are already criteria, but they are different for different methods of funding and managing health care. Is it worse to turn down a wealthy 75-year-old for a heart transplant, or to turn down a 30-year-old parent of a young family who's just getting by financially? By what criteria do you decide to do dangerous surgery, or another round of chemotherapy? Is it mainly by the likelihood that the patient will survive it and benefit from it, or does whether they can pay for it come into play? Compared to the US, Canadians with serious illnesses live about the same length of time, but at much lower cost. Physicians here are more likely to switch earlier to palliative care, focusing on quality of life, than to go for kill-or-cure efforts when the kill to cure ratio gets too high. ("Cure" here is figurative -- in such cases it's usually just greater palliation involved.) I recall a letter to the editor here some years ago. An elderly man was refused heart surgery because his chances of surviving it were only about 5%. His family pooled all their resources, went into debt, and sent him to a famous US hospital for the surgery. He had the good luck to survive, and his son wrote to the paper about the injustice of the system not providing the surgery here in Ontario. I thought about it and wondered how long after the surgery the elderly man survived, and how the family would have felt if their substantial financial sacrifice had resulted in the far more likely event that the man died on the table, depriving him of even the few months of life he might have had without the surgery. I can't guess if the family's guilt would have been greater in that case than if they had done nothing and let nature take its course. I certainly don't think they'd have written the same letter to the editor if the man had died in surgery. One might also wonder what fraction of the elderly man's remaining life was spent in pain and disability recovering from the massive trauma of open heart surgery, and if he regretted it, both for himself and for the effects on his children. At any rate, there aren't any easy answers, and while it may make decisions easier in a superficial way for the main criteria of how to treat to be what the patient can pay for, it must be hard on the physicians. When doctors return to Canada after working in the US for a while, this is one of the issues that affected their decision to return the most. (The other is quality of life in US vs Canadian cities.) There are a number of large-scale advantages to universal access to medical care. It's in the government's interest here for the population to be healthy (and paying taxes), so prevention and early detection of disease are encouraged and funded. Doctors here don't have to hire office staff just to deal with insurance, nor do they have to waste time hassling with insurance companies over whether treatment will or won't be funded. Data for the entire population of a province is accumulated centrally where it can be analysed for geographical trends and effectiveness of various treatment options. Global optimizations become possible -- encouraging and funding flu shots for the entire population reduces pressure on emergency rooms and demand for hospital beds in flu season because the elderly, who often become very seriously ill with flu and often don't respond effectively to immunizations, are surrounded by immunized people who can't transmit the virus to them. Note that a universal insurance scheme is vastly less expensive to manage than a private insurance company. About 30 years ago, Ontario collected premiums from employers and individuals. They decided to switch to a system of funding from a tax on employers and from general revenues, at immense savings in clerical and data processing expense: they closed down their entire data processing complex in Belleville. Now, they only deal with doctors and other providers and with employers instead of 10 million insured people individually or by family. Note that OHIP is not a business so it doesn't have to recompense shareholders or make a profit. It doesn't have to spend on selling or advertising or dunning letters or market research or actuarial decisions on who it will or won't cover, nor negotiating with doctors on whether individual patients are covered for various treatments. Another point -- malpractice suits are notoriously more common in the US and malpractice insurance is one of a doctor's major expenses, which further inflates the cost of medical care in the US. I wonder how much the drive to sue is fueled by the feeling of injustice that despite great financial sacrifice, there was a bad outcome? Or the belief that had there been more money, there would have been better treatment? Some stuff which gives me a serious headache because I agree with some and not with some and don't know what to think about the rest.... > There are a number of large-scale advantages to universal access to > medical care. It's in the government's interest here for the [quoted text clipped - 11 lines] > immunizations, are surrounded by immunized people who can't transmit > the virus to them. COMMENT: Absolutely. Preventive care is where government health programs really shine. People don't belong to even the best HMOs for long enough for even them to care about it THAT much. But most of your citizens in a country are with you from cradle to grave. Perhaps if we're going to experiment with "universal health care coverage" (aka socialized medicine) we should start with SOMETHING. So how about (at first) just the preventive stuff? Which would be... odd. Your vaccines and health checks, cancer screening of all kinds, blood pressure pills and all diabetes preventive care and meds, would all be totally taxpayer funded-- no co-pay. Ditto for all drug dependence and smoking treatment programs. But not your pain pills or trauma care or anything else you'd pay for anyway, when ill. The rule is universal coverage for things you have no incentive to do, but maintainance. For the other things, you'd still have to arrange for insurance. Teeth cleaning and filling would be paid for, but you get a severe financial going-over before the government paid for treatment of root abscess or tooth pulling or the kinds of things that happen if you DON'T take care of your teeth. Almost the complete opposite of what we do now. I'm not saying let patients with acute problems suffer. But do make them pay for non-preventive stuff if they have any extra money at all. The government would also handle data collection and some other things which suffer badly now, because of scale problems. We don't do enough experimentation in social programs. We should do a pilot program of this type in some state, and see what happens to health endpoints. Do we save total medicaid and medicare money? My bet is yes. COMMENT: > Note that a universal insurance scheme is vastly less expensive to > manage than a private insurance company. About 30 years ago, Ontario [quoted text clipped - 9 lines] > will or won't cover, nor negotiating with doctors on whether individual > patients are covered for various treatments. COMMENT: Sorry, but there's a big flaw in this argument. Advertising is data processing, and it's not useless, despite what commies think. Not only that, but competition is the mechanism by which waste and fat are flensed from any enterprise. Remove competition, and you get parasitical crud which cannot be removed by any other mechanism, and pretty soon that stuff outweighs everything else. Profits are merely pieces of information about what things are working efficiently. The free market beats command economies for one reason only: money and profit are the best markers for efficiency in large-scale enterprises which have ever been invented. Other methods may work for small groups like families or small communities where everybody knows everybody else. But for larger groups where strangers have to work together, it is prices and trade-efficiency which tell you about waste and screwing-up. >Note that OHIP is not a business so it doesn't have to recompense shareholders or make a profit.< And therefore is fiscally accountable to people who aren't nearly as interested in the results as are stockholders. Again, profits are INFORMATION ABOUT EFFICIENCY. Your average taxpayer doesn't know nearly as much about your government health program as your average stockholder does about the company whose shares he owns. All of this shows up in accountablity. If you don't give people a reason to think, they won't. Prices in a store when you go to buy something, are (again) almost PURE information. Remove them, and you get chaos. > [OHIP] doesn't have to spend on selling or advertising > or dunning letters or market research or actuarial decisions on who it > will or won't cover, nor negotiating with doctors on whether individual > patients are covered for various treatments. COMMENT: In place of dunning letters, it decides services have been stolen and sends the cops. But you don't count the police and the prisons as part of your "payment enforcement system" even though that's exactly what they are. Shifting business finanacial expenses from credit/loan/debt collection to cops and jails doesn't make them go away. It just makes them look like you're not paying for them. But of course you are. Besides, these decisions have to be made one way or the other. You think actuarial research doesn't have to be done at some point? Market decisions merely are merely "political decisions" if you remove the money incentive, but the information processing still must be done (and it won't be done as well). So what if you don't negotiate with doctors or patients about who will be covered for various treatments? Fine, but what makes you think somebody doesn't have to negotiate with *somebody else* to decide these matters? You want these negotiations to be with the people living with the disease and the effects of it, or some politician a thousand miles away who knows nothing about it? Which will give you the best and most informed decisions? Explain to me please why a national auto manufacturing association, with assignments for which citizens should be able to drive which cars, shouldn't be more efficient than a bunch but individual manufactures wasting money on advertising, and in wasteful individual negotiations with each prospective buyer! What a nightmare of waste! And yet there's so much difference between the needs of each individual, can you imagine how it would have to be handled if you had to do it centrally? And yet you propose to do it for an industry even more complex. Tell me the flaw in my thinking. > Another point -- malpractice suits are notoriously more common in the > US and malpractice insurance is one of a doctor's major expenses, which > further inflates the cost of medical care in the US. I wonder how much > the drive to sue is fueled by the feeling of injustice that despite > great financial sacrifice, there was a bad outcome? Or the belief that > had there been more money, there would have been better treatment? COMMENT: Suing the government is always harder. But this is not always a good argument for making the government responsible for any given enterprise. Be it making cars OR delivering medical care. SBH > Some stuff which gives me a serious headache because I agree with some > and not with some and don't know what to think about the rest.... [quoted text clipped - 141 lines] > > SBH Tell me the flaw in my thinking Steve invites. Here you are then: "... competition is the mechanism by which waste and fat are flensed from any enterprise. Remove competition, and you get parasitical crud which cannot be removed by any other mechanism, and pretty soon that stuff outweighs everything else. Profits are merely pieces of information about what things are working efficiently. The free market beats command economies for one reason only: money and profit are the best markers for efficiency in large-scale enterprises which have ever been invented. Other methods may work for small groups like families or small communities where everybody knows everybody else. But for larger groups where strangers have to work together, it is prices and trade-efficiency which tell you about waste and screwing-up." Statins make multiple millions upon millions for shareholders every year. Drugs shilled for a disease that doesn't exist. To do no-one knows what. Profit. They make a lot of profit; while creating injured living unproductive limping lives, sliding into dying from the drug and the drug induced diseases. This is an example of profits being pieces of information about what things are working efficiently. "outrider" <outrider@despammed.com> wrote in message news: > Tell me the flaw in my thinking Steve invites. Here you are then: > [quoted text clipped - 11 lines] > have to work together, it is prices and trade-efficiency which tell you > about waste and screwing-up." Correct and internally consistent. I welcome your dissention. But it will never come. > Statins make multiple millions upon millions for shareholders every > year. Drugs shilled for a disease that doesn't exist. To do no-one > knows what. Profit. They make a lot of profit; while creating injured > living unproductive limping lives, sliding into dying from the drug and > the drug induced diseases. This is an example of profits being pieces > of information about what things are working efficiently. If you can prove that statins are sold under the auspices of a conspiracy, then you have something. But, you won't. Fortunately, you can officially avail yourself of plenty of money liberated from taxpayers and feel proud to have defended legalized larceny. You have no friends here. I'd recommend a sock-puppet to pump you up. moo > "outrider" <outrider@despammed.com> wrote in message news: > > Statins make multiple millions upon millions for shareholders every > > year. Drugs shilled for a disease that doesn't exist. To do no-one [quoted text clipped - 10 lines] > > moo COMMENT: Christ. This reminds me of the AIDS deniers, who vasilated between the idea that HIV doesn't exist, or else that it does, but is harmless and AIDS, as an infectious disease doesn't "exist" (rather, it's just a giant phara conspiracy fronted by shills). This went on for quite awhile and provided quite a lot of sparks back during the days when the anti-HIV drugs weren't much good. About 1995 the protease inhibitors arrived and high active antiretroviral cocktails began to be possible. The HIV-infected HIV skeptics who had low lymphocyte counts were then faced with a grim choice: take the drugs and admit they were wrong, or else die. Some of them chose to die. The rest of them now take the drugs and have shut up. The only people we really have left in the debate are the people who never had HIV to begin with, or else are among the small and lucky group who actually can live wtih HIV without much viral reproduction or immunosuppression, even without the drugs (10 to 15%). These last group of people cause hell of course, because some of them are narcisists. THey figure if the HIV doesn't harm THEM, why then, it can't be harming *anybody.* Because their own experience trumps that of the WHOLE world. Hey, I don't wear MY seatbelt and *I've* never been hurt! And therefore the entire world MUST BE engaged in a VAST conspiracy to make everybody with their diagnosis do something none of them would really benefit from doing. It's sort of like those 85 year-old 3-pack-a-day smokers you find now and again, puffing away and cackling about the stupid health nuts. People who happen to win at slots sometimes think the light of God shines directly upon them. It's infantile, but some people never quite grow up. SBH Are you saying the situation with statins and cardiovascular disease is analagous to the situation with AIDS drugs and AIDS? So ... then, you're ok with putting people on AIDS drugs to prevent AIDS are you? Zee > > "outrider" <outrider@despammed.com> wrote in message news: > [quoted text clipped - 47 lines] > > SBH "outrider" <outrider@despammed.com> wrote in message > Are you saying the situation with statins and cardiovascular disease is > analagous to the situation with AIDS drugs and AIDS? > > So ... then, you're ok with putting people on AIDS drugs to prevent > AIDS are you? Only an idiot would interpret it that way. The comments are in direct response to the following claim made by said idiot: "Statins make multiple millions upon millions for shareholders every year. Drugs shilled for a disease that doesn't exist. To do no-one knows what." Fair use. moo > Zee > [quoted text clipped - 54 lines] >> >> SBH > Perhaps if we're going to experiment with "universal health care > coverage" (aka socialized medicine) we should start with SOMETHING. So > how about (at first) just the preventive stuff? Preventive stuff costs MORE. > > Perhaps if we're going to experiment with "universal health care > > coverage" (aka socialized medicine) we should start with SOMETHING. So > > how about (at first) just the preventive stuff? > > Preventive stuff costs MORE. COMMENT: That depends. I very much doubt that polio vaccine costs more than dealing with polio. SBH >Some stuff which gives me a serious headache because I agree with some >and not with some and don't know what to think about the rest.... I know what you mean. This happens to me too. The only thing I can suggest is to keep thinking until you decide which of the third class belongs in the first or second. Or else, just ignore stuff on usenet that makes your head hurt. >> There are a number of large-scale advantages to universal access to >> medical care. It's in the government's interest here for the [quoted text clipped - 43 lines] >health endpoints. Do we save total medicaid and medicare money? My bet >is yes. I don't have enough knowledge of your system to comment on the feasibility of your ideas. >> Note that a universal insurance scheme is vastly less expensive to >> manage than a private insurance company. About 30 years ago, Ontario [quoted text clipped - 27 lines] >have to work together, it is prices and trade-efficiency which tell you >about waste and screwing-up. I'm not a "commie" and I don't think advertising or profits or competition or most of the other components of a capitalist economic system are intrinsically bad. However, I don't think that every area of human endeavor works best under laissez faire capitalism. Right now, my property taxes pay for the municipal fire department. They do a good job, and I am quite willing that my taxes support them. Suppose instead there were a dozen competing fire departments that I could choose from to put out fires on my property. Each one would have to spend on advertising and sales, collecting fees from its customers, dispatchers and enough staff and equipment to handle fires in every area of the city even though its competitors have eleven times the equipment and staff there already. If I see flames shooting from my neighbour's roof, who do I call? If a house covered by company A is adjacent to houses covered by company B, C...L, who gets called? Who prevents the flames from reaching the nearby houses? Who gets to use the fire hydrant for its hoses? Maybe each company will have to have its own system of water mains and hydrants. What's more, since everybody will want a fire department to protect them, but major fires are actually quite rare, the best way for a fire department to be profitable is to charge low fees, and provide poor service. This is how property and auto insurance already works -- an insurance company that charges low premiums can do so because it rejects many claims. I learned this by working with insurance brokers for a good many years. Several well-known and very successful insurance companies are noted for this. It's not dishonest or unethical -- it's just an example of getting what you pay for. Note that my fire department does advertise, as does OHIP. The fire department advertises to recommend smoke detectors, that people check their homes for fire hazards and figure out escape routes, etc. OHIP advertises to recommend flu shots, assistance in stopping smoking, screening for cervical cancer, diabetes, hypertension, etc, breast feeding, folic acid for women who want to become pregnant and a variety of other periodic campaigns. >>Note that OHIP is not a business so it doesn't have to recompense shareholders or make a profit.< > [quoted text clipped - 6 lines] >they won't. Prices in a store when you go to buy something, are (again) >almost PURE information. Remove them, and you get chaos. Well, it depends on what your goals are. If you are a for-profit corporation, your chief goal is to make profits for your shareholders. That's capitalism, and I am not objecting to it. If your goal to is provide good health care to all members of society, independent of their ability to pay, it helps a lot not to have to make short term profits for shareholders, or have to budget a great deal of money to acquire customers and receive and process their premiums and keep track of who's paid up and who's entitled to what and all the overhead involved in running a for-profit corporation. Just as my local fire department doesn't have to spend resources on competing with other fire departments, or pleasing shareholders whose interest is in how much money their investment can provide them independent of how they conduct their business. Efficiency is good, but you can only evaluate efficiency relative to your goals. A health insurance company may be very efficient and profitable if it can avoid insuring high risk people and disallow many claims. It can offer low premiums, and attract many customers who will be very happy until, possibly after many years, they find out just how much good the company will do them when they run up substantial bills or develop a condition that puts them in a high risk group. The company is quite legitimately in business to make money, and it is doing so efficiently. It's not in business to provide lifelong health care to the whole population independent of ability to pay, and it doesn't do so. >> [OHIP] doesn't have to spend on selling or advertising >> or dunning letters or market research or actuarial decisions on who it [quoted text clipped - 8 lines] >away. It just makes them look like you're not paying for them. But of >course you are. Well, since the services are covered for everybody the only people who can steal services are non-residents of Ontario. It's true they are hard to catch. When there got to be too many people sneaking in from the US to steal services, OHIP went to photo-ID cards from the previous plain plastic ones, which apparently helped a lot. No giant penological expenses involved. Doctors do occasionally get caught committing fraud, but I don't think you'd regard it as okay to defraud OHIP but not a private insurance company, would you? >Besides, these decisions have to be made one way or the other. You >think actuarial research doesn't have to be done at some point? Market [quoted text clipped - 7 lines] >politician a thousand miles away who knows nothing about it? Which will >give you the best and most informed decisions? My point is that both the doctors and the insurance companies in the US spend a lot of time and money hassling about innumerable individual cases about coverage. AFAIK, it's common for a doctor in private or small group practice to have to hire a specialist clerk just to deal with all the insurance paperwork, and US doctors in this newsgroup often mention how much they dislike wasting time arguing on the phone with low level clerical workers at insurance comapnies. A single payer makes a huge difference in the amount of resources that need to be spent on getting paid for services rendered, and this applies to every place services are rendered, including hospitals. Resources not spent on data processing can be spent on patient care, or not acquired out of anybody's pocket in in the first place. I'm not a doctor, although I have worked with doctors. As I understand it, doctors are given rather flexible guidelines on what is and isn't covered for whom. E.g. a family physician can consult a guideline on whether blood lipids should be screened for routinely in a patient. I've seen such a list, and IIRC the criteria included age, sex, family history, some specific risk factors and medical conditions, and the last one was "if the patient is particularly concerned". I think these guidelines may be on the Ontario Ministry of Health web page, if you want details. Of course, not all procedures are covered, or not for all cases. Some years ago they decided to stop covering IVF, first for women over 40, for whom the success rate was very low at the time, and later entirely. Women who want this procedure can purchase it at a private clinic. Similarly, plastic surgery may or may not be covered -- if it's to repair injury from trauma or disease, it usually is. If you want other procedures, you pay for them yourself. >Explain to me please why a national auto manufacturing association, >with assignments for which citizens should be able to drive which cars, [quoted text clipped - 5 lines] >centrally? And yet you propose to do it for an industry even more >complex. Tell me the flaw in my thinking. I'd say the flaw in your thinking is the standard rhetorical fallacy of False Analogy. How's that? This reminds me of the standup comic joke about the greedy girlfriend: "She wanted me to buy her something really expensive that she didn't need, so I booked her in for chemotherapy." >> Another point -- malpractice suits are notoriously more common in the >> US and malpractice insurance is one of a doctor's major expenses, which [quoted text clipped - 8 lines] >argument for making the government responsible for any given >enterprise. Be it making cars OR delivering medical care. Doctors here don't work for the government, they work for hospitals, clinics, partnerships, individual practices etc. They just bill one insurer instead of many. If my doctor cuts off the wrong leg, I sue him, not the government. My point is that if I go bankrupt unsuccessfully trying to save my loved one's life, I'm more likely to feel the need to blame someone and recover something than if I had only the emotional trauma of dealing with it. Left after the funeral broke and in debt, I'm more likely to believe that the doctors just soaked me and let my loved one die. I'll want revenge and compensation. I'm not saying this is reasonable -- quite the contrary -- but it seems like many people might react this way. Fear of malpractice suits and cost of malpractice insurance here don't seem to be the crushing burdens they are for many doctors in the US. They don't drive doctors out of certain specialties or absorb a substantial fraction of their professional income. I'm speculating above why this may be the case. I'm not saying that the system here in Ontario, or in any other province, or in any of the developed countries of the world other than the US is ideal and problem free. They all have problems. But the evidence is that people here seldom get into serious financial straits due to medical costs, they can obtain medical care without worrying whether they can pay for it, their life expectancy both in general and after acquiring a serious disease is comparable or better than that in the US, health care costs much less per capita than in the US, people don't feel that they are taxed excessively for this service, and they feel the treatment they receive is adequate and of good quality. Not everybody is satisfied, everyone sees some problems, but most people feel reasonably well done by. > >Some stuff which gives me a serious headache because I agree with some > >and not with some and don't know what to think about the rest.... [quoted text clipped - 3 lines] > belongs in the first or second. Or else, just ignore stuff on usenet > that makes your head hurt. Ditto! Let's give a slightly different scenario/example: worldnetdaily.com. At first reading this site seems like a fairly interesing, alternative media conservative site, and it does often offer usefull news not seen in the MSM, but on further reading you see they are pro-creation, anti-evolution, jesus, jesus, jesus, etc. The absolute BOTTOM of the socially acceptable ladder in this country is the "freethinking" RIGHT. By this I mean the rightwing atheists. If you're one of these you're a "hater" or a "fascist" or a ... You're not even given the benefit of "having good intentions" that the leftwing atheists are given. >Sorry, but there's a big flaw in this argument. Advertising is data >processing, and it's not useless, despite what commies think. Not only [quoted text clipped - 10 lines] >have to work together, it is prices and trade-efficiency which tell you >about waste and screwing-up. >I'm not a "commie" and I don't think advertising or profits or >competition or most of the other components of a capitalist economic [quoted text clipped - 13 lines] >the fire hydrant for its hoses? Maybe each company will have to have >its own system of water mains and hydrants. COMMENT: Or maybe they'll all cooperate to get end-user stuff to you, as would water and sewage departments. It can be done, you know. People used to laugh at the idea of competing power companies, but Lubbock, Texas actually has two--- complete with two sets of (in many places duplicate) powerlines. If you want to change from one company to the other, there's a check to see that your bills are paid up, and then somebody comes over to run a tap from your place to the other distribution system. These don't NEED to be duplicated, if everybody goes in on the end-use distribution, as happened no long ago with telephone companies. We removed the "natural monopoly" created by the fact that one company had built all the phone line infrastructure, and simply let anybody use it. That wasn't very fair, but there are ways of encouraging companies to do the end stuff by promising them license right for a certain period of time (but not forever) if they install it. That's happening with cable, and will likely be the mechanism for getting fiberoptic into every home. You don't think ONE company OR the government will own that system, do you? And yet, probably every home will have only incoming fiber line. More would we ridiculous, considering the capacity. So fiber-optics is like plumbing, but monopoly or government control are not necessary. The analogy of the fire department is not a good one, because when one house goes it takes neighboring ones with it, so it's essentially a community problem by the very physical basis of it, somewhat like air pollution. Since one house-owner's risk is everybody's, and can't be parceled out or divided (with one guy wanting to pay for more protection from fire and another guy next wanting less), it seems that a general democratic consensus for a single level of protection for any unit of physically contiguous structures must be reached. Many aspects of police protection are the same, since burglars and vandals are somewhat like fires (if you don't want to pay your police much to watch YOUR property, it affects MY property next door in somewhat the same way as if you scrimp on your fire production). But there are few things in life that actually run that way, and medical care isn't one of them. If somebody's getting mugged, it's hard to tell in the time you have what private police protection service you call for him. But it's much easier to tell about his medical coverage. Nor do his bad medical decisions affect other people in the same way they would if he scrimped on fire or garbage removal. That being said, if the community as a whole decides it absolutely cannot stand for uninsured lying in the gutter until they die, then some kind of community decision has to be made on minimal care for the uninsured. My problem is that invariably gets used as a back door invasion of privacy, since the community invariably decides that if it pays the bills, it should have some say in the risks the person takes to generate them. Which goes back to every aspect of life style (think of seatbelt laws and you get the idea). >What's more, since everybody will want a fire department to protect them, but major fires are actually quite rare, the best way for a fire department to be profitable is to charge low fees, and provide poor service. This is how property and auto insurance already works -- an insurance company that charges low premiums can do so because it rejects many claims. I learned this by working with insurance brokers for a good many years. Several well-known and very successful insurance companies are noted for this. It's not dishonest or unethical -- it's just an example of getting what you pay for.< COMMENT: Indeed, but I covered that. It's FINE for people to want to pay less and accept that they then get less. And except in the case of some really bleed-over things like fire, it can be done in just that way. >Note that OHIP is not a business so it doesn't have to recompense shareholders or make a profit.< >And therefore is fiscally accountable to people who aren't nearly as >interested in the results as are stockholders. Again, profits are [quoted text clipped - 4 lines] >they won't. Prices in a store when you go to buy something, are (again) >almost PURE information. Remove them, and you get chaos. >Well, it depends on what your goals are. If you are a for-profit corporation, your chief goal is to make profits for your shareholders. That's capitalism, and I am not objecting to it. < COMMENT: Yes, that's your goal. But along the way, it also allows you to be maximally efficient at delivering a given service for a price. You city as a whole probably WOULD benefit if it could contact (as a unit) with competing fire departments, because it would find out in that case that a lot of fire service money gets wasted now. >If your goal to is provide good health care to all members of society, independent of their ability to pay, it helps a lot not to have to make short term profits for shareholders, or have to budget a great deal of money to acquire customers and receive and process their premiums and keep track of who's paid up and who's entitled to what and all the overhead involved in running a for-profit corporation. Just as my local fire department doesn't have to spend resources on competing with other fire departments, or pleasing shareholders whose interest is in how much money their investment can provide them independent of how they conduct their business.< No, wrong, wrong, wrong. As well say If your goal to is provide good nutrition to all members of society, independent of their ability to pay, it helps a lot not to have to make short term profits for grocers or food distributors, or have to budget a great deal of money to acquire customers of farmers and receive and process their bids for next years crops and meat and keep track of who's paid what and who's entitled to what, and all the overhead involved in running a for-profit corporation, which any modern farm certainly is, and which most food distributors and outlet are also. Let's just socialize all that. Look at all the duplication and the guessing with the porkbelly futures and so on. For godsake, just grow the food for people who need it, okay? >Just as my local fire department doesn't have to spend resources on competing with other fire departments, or pleasing shareholders whose interest is in how much money their investment can provide them independent of how they conduct their business.< COMMENT: Just as my local grocery store (farm, restaurant, whatever) doesn't have to spend resources on competing with other stores (farms, restaurant, whatever) or pleasing shareholders whose interest is in how much money their investment can provide them independent of how they conduct their business. Right. Let's just eliminate the profit angle, and feed everybody for less, by cutting out all that investment and competition between grain in the field, and the hamburger on the table. >Efficiency is good, but you can only evaluate efficiency relative to your goals. A health insurance company may be very efficient and profitable if it can avoid insuring high risk people and disallow many claims. It can offer low premiums, and attract many customers who will be very happy until, possibly after many years, they find out just how much good the company will do them when they run up substantial bills or develop a condition that puts them in a high risk group. The company is quite legitimately in business to make money, and it is doing so efficiently. It's not in business to provide lifelong health care to the whole population independent of ability to pay, and it doesn't do so.< COMMENT: No, but again, you're not making a very good argument as to why Canada shouldn't have an entire separate socialized government farming and food processing facility for the purpose of feeding those who don't have enough money for food. And thence also to housing and whatever. What's special about medical care? Medical insurance is NOT like fire insurance or police insurance. It's rather more like auto insurance (do you have AAA up there?). If some people are too poor to afford auto insurance and you decide they need it anyway, the solution isn't to have the government go into, or take over, the auto insurance industry, anymore than you can justify the government taking over the entire food industry because some people can't pay enough to eat well. >Explain to me please why a national auto manufacturing association, >with assignments for which citizens should be able to drive which cars, [quoted text clipped - 5 lines] >centrally? And yet you propose to do it for an industry even more >complex. Tell me the flaw in my thinking. >I'd say the flaw in your thinking is the standard rhetorical fallacy of False Analogy. How's that?< COMMENT: It's glib and not good enough, is what. You have to explain what makes it a false analogy, and what it is about medical care which makes it so inherently different from producing food or cars or any other good or service which is inherently personal (not like fire or police protection), that the ordinary laws of market efficiency do not apply to it. It ISN'T that some people can't afford it, because (as noted) some people can't afford food or housing or clothes and almost any good or service you can think of that is for sale on the free market. Government solves THAT problem by simply providing people with some credit, as for food stamps (actually we have a plastic Electronic Benefits Transfer = EBT card, which now does the same thing), and not worrying that use of the EBT card at a grocery store thereby helps pay for grocery store advertising, or farm-vs-farm livestock competition, etc. >Suing the government is always harder. But this is not always a good >argument for making the government responsible for any given >enterprise. Be it making cars OR delivering medical care. >Doctors here don't work for the government, they work for hospitals, clinics, partnerships, individual practices etc. They just bill one insurer instead of many. If my doctor cuts off the wrong leg, I sue him, not the government. < COMMENT: Yes, but cutting off the wrong leg is not what doctors get sued for in the US. It's not what we do that's found wrong, it's generally what we FAIL to do. The most common lawsuit is failure to find cancer soon enough. Followed by suits related to damaged babies (presumably related to failure to do C-sections soon enough, I suppose). Canada gets around that by setting the standard for what doctors are supposed to be doing. You can sue the doctor for not doing it, but he has the perfect defense: he didn't do it because the government wouldn't pay him to, and that's the end of it. What the doc "should" be doing is what the government covers. Very simple. In the US it is made all very complicated by multiple sets of standards for what the insurers will and won't pay for. I admit that this could be greatly simplified, but it's not clear to me that total government takeover is needed. For heavensake if government has solved this problem for government food stamps, it can do a lot of it for medicine. If you try to use EBT card to buy a fastfood like a hamburger, or cigarettes or beer, or non-food items, the computerized system goods "GLEEP" and won't let you do it. In a similar way, the way government takes care of medical care for poor people in one of my states is it simply enrolls them in one of a couple of competing HMOs, and gives them an HMO card. What they get for that, is then clear from the HMO rules. And it's harder for them to sue about what they don't get, in very much the same way it is in Canada. BUT people who can pay more don't have to use the system, and doctors don't have to, either, unless they want to work for one of those particular HMOs. >I'm not saying that the system here in Ontario, or in any other province, or in any of the developed countries of the world other than the US is ideal and problem free. They all have problems. But the evidence is that people here seldom get into serious financial straits due to medical costs, they can obtain medical care without worrying whether they can pay for it, their life expectancy both in general and after acquiring a serious disease is comparable or better than that in the US, health care costs much less per capita than in the US, people don't feel that they are taxed excessively for this service, and they feel the treatment they receive is adequate and of good quality< COMMENT: Yes, and I've speculated on some of the reasons for that. Without question we waste a lot of health care dollars in the US by having no co-pay (so the customer doesn't assist in the monitoring), but at the same time not having the government ration expensive and fairly worthless technology, either. So we get the worst of both worlds, being taxed for somebody ELSE'S luxury medical scan or angiogram. The other problem is that Canada really does ride the US coattails in terms of research and medical technology development, and that's like having to be the front windbreak biker in a racetrack bike race ALL the time. It gets to be very old, after a while. And it always makes #2 look better than he really is. There's also a completely different attitude toward medical care in the US-- one which I can only characterize as "technology and money and complaining can get you anything." In Canada it's more of a Roman Catholic or Episcopal attitude, which is you do what you can, and ask politely, and after that, you accept what you get. The opposite attitude is associated with, well, let's just say non-Catholics. SBH Steve, your posting software is not distinguishing who wrote what properly. What I wrote and you wrote are indistinguishable. If you indicate who wrote what by means that don't show up in plain ascii text, you're going to continue to confuse people. Please, do me, at least, the favor of using standard quoting to make things clear. I'm sure your favorite posting software will do this for you readily. At any rate, sci.med isn't a good venue for discussing issues of political economy, that isn't my favorite area of discussion, and I don't feel a strong need to either persuade or be persuaded by you. Perhaps other people in talk.politics.medicine, which I don't read, would like to continue. As for comparing supplying medical care to supplying food, it's not the best analogy either. Also note that US farmers are so heavily subsidized by the US federal government that many make most of their income from subsidies. I don't think you are familiar with how universal medical care is managed in the many jurisdictions of the world that provide it. You make a lot of incorrect assumptions, often combining the worst problems of several different systems, and attack these straw men. I also think it's wrong to assume that every country should do things the same way, or that there's only one right way to do anything. It's very common among Americans to believe that their way is the only correct one, and it creates a lot of bad feeling towards the US in other parts of the world. This is pretty much my bottom line: >>I'm not saying that the system here in Ontario, or in any other province, >or in any of the developed countries of the world other than the US is [quoted text clipped - 14 lines] >worthless technology, either. So we get the worst of both worlds, being >taxed for somebody ELSE'S luxury medical scan or angiogram. Well, we like our system, so why do you think it's so horrible and wrong and we are stupid not to go to a system like the US? >The other >problem is that Canada really does ride the US coattails in terms of >research and medical technology development, and that's like having to >be the front windbreak biker in a racetrack bike race ALL the time. It >gets to be very old, after a while. And it always makes #2 look better >than he really is. I don't think this issue is relevant to how medical care for individuals is funded, but I'll address it anyway. I won't address where funding for medical and scientific research should come from. Presently a great deal of it comes from governments, and there can be serious conflict of interest problems when it comes from for-profit corporations. Both countries benefit from research done in Europe, Japan and elsewhere. Canada has only a tenth the population of the US, so if funding were equal on a per capita basis, it would result in technology transfer from the US to Canada anyway. There's also the question of how research grant money is used. As I understand it, in the US, a substantial fraction of a scientist's grant goes to overhead and is claimed by his institution before he ever sees it. Granting agencies take this into account when determining the amount of the grant -- if they want the researcher to have $x to work with, they'll give him $2x or whatever is needed to cover the overhead. In Canada, researchers don't pay overhead from their grants to the institutions at which they work. The institutions (universities, research institutes, etc) are funded separately. So comparing money spent on research in the two countries is not at all straightforward. Also, money spent on a problem isn't a good measure of the quality or quantity of solutions you get. There are quite a few good scientists in Canada, and they are doing good work in both pure and applied research, both locally and in collaboration with scientists in the US and elsewhere. When I read the technical literature in the several fields I'm interested in, I see numerous papers with authors and co-authors who are not at US institutions. I observe that a lot of high tech medical equipment comes from European and Japanese companies, and European pharmaceutical companies develop a lot of drugs. The US isn't the one and only "front windbreak rider" in every field. >There's also a completely different attitude toward medical care in >the US-- one which I can only characterize as "technology and money >and complaining can get you anything." In Canada it's more of a Roman >Catholic or Episcopal attitude, which is you do what you can, and ask >politely, and after that, you accept what you get. The opposite >attitude is associated with, well, let's just say non-Catholics. Steve, you've never lived in Canada, you don't know much about the country, its history, its economy, its religions, its political and social systems, or how its great diversity of people view the problems of life. Don't you think you may be jumping to conclusions? If you're generalizing from the few identifiably Canadian posters to this newsgroup, you should realize that they're not likely to be a representative sample. > There are always cases of limited resources. You can't transplant a > liver into everyone who needs one because there aren't enough livers [quoted text clipped - 11 lines] > come into play? Compared to the US, Canadians with serious illnesses > live about the same length of time, but at much lower cost. That really bothers the American medial/industrial complex because they want to criticize Canada because they hate anyone knowing that spending twice as much gets you nothing in terms of life expetancy. >Do we or do we not transplant every long-term alcoholic with liver >disease? Do we let nature take its course if someone >can't/won't/don't follow medication requirements for HIV drugs? Do >we chemo everyone over 75? We need to stop making influenza vaccines! > This would indicate that we expect do everything for >everybody. ========================= "Endeavor to persevere" ========================= > The reality: Drug costs (particularly cancer drugs) are skyrocketing, > and the benefits of new drugs are often marginal. Despite the > pharmaceutical company bumph -- and what patients themselves > desperately want to believe -- miracles are few and far between, and > cures are even more elusive. In many cancers, a 2 month difference in life expectancy is considered optimal. > In many cancers, a 2 month difference in life expectancy is considered > optimal. Oh, bullshit, George. SBH |
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