Friday, September 23, 2011

Rationing Abroad and At Home

Because of the debt crisis in Greece, government-run hospitals can't pay their bills.

Hence, patients aren't receiving medically necessary drugs. As Avik Roy notes, "Our future is Greece's present".

Closer to home, physician-blogger "Shadowfax" describes the proposed new indirect rationing system in Washington state.

Medicaid patients in WA are being told that if they use the ER for non-emergency purposes, then the state won't cover their costs. So this puts the hospitals and doctors in a tricky position.

The ER doctors could turn away those patients. But then they might run afoul of EMTALA laws which require the ER staff to evaluate the patient sufficiently to determine whether or not there is a genuine medical emergency.

Or they could see these patients and provide some level of services -- but risk not getting paid. (The hospital can attempt to bill these Medicaid patients, but realistically they almost certainly won't collect anything.)

So the proposed non-payment rules essentially put the ER doctor in a no-win position of rationer-by-proxy. The government will punish him financially if he doesn't save money for the government, but punish him legally if he fails to provide medically necessary emergency services.

To make matters worse, the list of supposedly "non-emergency" medical conditions the state won't cover includes:
Chest Pain
Abdominal Pain
Asthma Exacerbation (acute)
Acute Cholecystitis
Hypoglycemic Coma
Pneumococcal Pneumonia
Do you want the government deciding that a coma isn't a true emergency?

Or if a patient comes in with bad chest pain, neither the doctor nor the patient can always distinguish between something serious (like a heart attack) or something more benign (such as severe indigestion) without a variety of tests.

If it turns out that the patient's chest pain was just an unusually severe case of indigestion, the state gets to say to the hospital, "See it wasn't really anything too bad, so we won't pay you for performing all those unnecessary tests. They weren't really cost-effective use of scarce resources for indigestion."

Of course, the problem is that you don't know until after you run the tests that it wasn't anything too serious. The government gets to claim the benefits of 20-20 hindsight that it impossible for a doctor at the time the patient arrives in the ER.

Do we really want this kind of government-run medical system?