Hsieh Forbes Column: Who Decides What Medical Care You Receive At End of Life?

My latest Forbes column was posted yesterday, "Who Decides What Medical Care You Receive At End of Life?"

I discuss how some patients in the socialized medical systems of Canada and the UK have been put on DNR ("do not resuscitate") status without their knowledge or consent and how that ties to the current debate over government-funded end-of-life counseling here in the US.

As I've said before: If you expect “somebody else” to pay for your health care, then “somebody else” will ultimately decide what care you may (or may not) receive.

I also discuss how free-market reforms for health insurance can protect patient choice in end-of-life medical decision-making.

And for some excellent practical advice on how patients can plan for such eventualities, check out this interview with Dr. William Dale by my wife Diana.

Who's Paying For Health Care?

Who's paying for health care?

According to Investor's Business Daily, the government is paying for 46% of our nation's health care, and that percentage will continue to grow.

Federal, state and local governments will spend a total of $1.4 trillion on health care this year, which will account for a record-high 46% of the nation's total health care tab, according to spending data released by the Centers for Medicare and Medicaid Services.

That's up from the government's 39% share just a decade ago, and the share is expected to hit 48% by 2023, as government programs continue to grow faster than the overall health care economy, the report found.

And of course, he who pays the piper calls the tune.

If you expect "somebody else" to pay for your health care, don't be surprised if "somebody else" decides what health care you will (or will not) receive.

Re-unite Consumer of Health Care with Payer of Health Care

Dr. Timothy Wingo explains that we should, "Re-unite the consumer of healthcare with the payer of healthcare".

He explains how in his Forbes piece, "Concierge Medicine For All: Direct Primary Care Is The Solution For Our Health Care System.

An excerpt:

However, starting several decades ago, we were sold on the idea that health insurance should cover everything including routine primary and preventive care; and once we paid our premiums, or they were paid on our behalf by taxpayers, we could expect extensive work-ups to be done with little thought of the costs.  If the additional cost to us was very little, why not?  We believed that more care was better care. Whether or not it was necessary rarely factored into our thoughts.  Doctors, needing to protect themselves from malpractice liability, and not having time to educate patients or argue, would oblige us as it also made them more money. The insurance companies, paying for all of this care, then started charging higher premiums, implementing higher deductibles, co-pays and co-insurances…and the cycle continued.

In large part because of this, doctors have faced increasing bureaucratic regulations from government and insurance companies in an attempt to control costs.  This has lead to doctors getting reimbursed very little for their time despite them spending 12-plus years in training and a few hundred-thousand dollars for that education....

This explains why doctors rush through appointments and spend very little time with patients.  In an attempt to not miss a diagnosis, not disappoint patients, and protect themselves from liability, they order multiple tests.  This makes hospital administrators all too happy. They really don’t expect to make a profit on their employed doctor’s time, they expect to make it off of the ancillary services he orders.  Some of these profit margins can exceed 10,000 percent!

So what is the solution?  Re-unite the consumer of healthcare with the payer of healthcare...

Contrasting Headlines

Here are a couple of contrasting headlines that came through my newsfeed recently.

"Peter Thiel: the billionaire tech entrepreneur on a mission to cheat death" (The Telegraph, 9/19/2014)

"Why I Hope to Die at 75" (Ezekiel Emanuel, The Atlantic, 9/17/2014)

Gunderman on How To Discourage a Doctor

Dr. Richard Gunderman describes the "playbook" of those who wish to control physicians for their own ends. His article was written about what physicians should expect from hospital executives, but it applies just as well to physican relationships with bureaucrats and others seeking to bring medical care under greater government control.

From his piece, "How To Discourage A Doctor":

Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are.

Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus...

Hence, those steps include:

• Make healthcare incomprehensible to physicians.
• Promote a sense of insecurity among the medical staff.
• Transform physicians from decision makers to decision implementers.  
• Subject physicians to escalating productivity expectations.
• Increase physicians’ responsibility while decreasing their authority.
• Above all, introduce barriers between physicians and their patients. 

He discusses each point in greater depth in the full article.

Given all this, one way for physicians and patients to best protect themselves is to allow patients to control their own medical spending. This allows doctors to treat the patient as "boss".  Various models such as Health Savings Accounts (for patients) and direct-pay practices (for physicians) work nicely together to protect that vital doctor-patient relationship. 

As Sun Tzu said, "Know Your Enemy".  His advice applies just as well today as it did in ancient China.

Venezuelan Breast Implant Shortage

The New York Post reports, "Venezuela has chronic shortage of breast implants":

Beauty-obsessed Venezuelans face a scarcity of brand-name breast implants, and women are so desperate that they and their doctors are turning to devices that are the wrong size or made in China, with less rigorous quality standards.

Venezuelans once had easy access to implants approved by the US Food and Drug Administration. But doctors say they are now all but impossible to find because restrictive currency controls have deprived local businesses of the cash to import foreign goods. It may not be the gravest shortfall facing the socialist South American country, but surgeons say the issue cuts to the psyche of the image-conscious Venezuelan woman...

As Dr. Megan Edison quipped online, "The problem with socialism is that eventually you run out of other people's breast implants."

Potential Perils of Personal Genetic Testing

Biologist "George Doe" (a pseudonym) described how: "With genetic testing, I gave my parents the gift of divorce".

I'm glad the 23andMe service allows people the option of learning about close relatives. But a couple of take home points:

1) If you get a 23andMe genetic test, make sure you really really want to know if you might have genetically close unknown relatives before you click through on that part of the results.

2) If you have a child you didn't tell your current family about, maybe you should come clean before you get your 23andMe test.

Related: "Genetic testing brings families together. And sometimes tears them apart".

Suspended Animation Update

From The Economist: "Doctors have begun human trials of suspended animation to buy more time for critically injured patients".

The article explains:

Dr Tisherman’s EPR process, developed with the help of $800,000 from the Department of Defence, is mostly about resurrection. The idea at this stage is to use equipment like the catheters and pumps that can be found in any trauma centre to suspend the life of critically injured people in order to buy more time for surgeons to try to save them.

EPR works by lowering the patient’s body temperature and replacing their blood with a cold saline solution. Hypothermia is already induced in patients to help reduce bleeding during some surgical procedures. But cooling the body down so that it goes into a suspended state has not been tried before. The idea came from observations that people have been resuscitated having stopped breathing for half an hour or more after falling into icy water.

I'm encouraged by this kind of medical advance.  One interesting quote from the article:

The Food and Drug Administration decided the procedure was exempt from informed consent, as patients would be too ill to give it themselves and might benefit because they were likely to die as no other treatment was available. For now, the patient has to be between 18 and 65 years old, have a penetrating wound, such as a knife, gunshot or similar injury, suffer a cardiac arrest within five minutes of arrival in the hospital and fail to respond to usual resuscitation efforts.

Given that these patients would like die anyways without the experimental treatment (and that they presumably want to live), one can make a much stronger case for waiving the usual informed consent in this kind of emergency than in the more-controversial UK experiment (which involves giving standard adrenaline therapy vs. placebo to cardiac arrest patients.)

For more on the latter topic, see my recent Forbes piece, "UK To Experiment on Cardiac Arrest Patients Without Their Consent".

Why Much of the Medical Literature Is Wrong

Medscape: "Why Much of the Medical Literature Is Wrong".

Topics discussed include:

1. Reverse Causality
2. The Play of Chance and the DICE Miracle
3. Bias: Coffee, Cellphones, and Chocolate
4. Confounding
5. Exaggerated Risk 

Some eye-opening examples:

Mistaking what came first in the order of causation is a form of protopathic bias.^[4] There are numerous examples in the literature. For example, an assumed association between breast feeding and stunted growth, ^[5] actually reflected the fact that sicker infants were preferentially breastfed for longer periods. Thus, stunted growth led to more breastfeeding, not the other way around...

One classic example of selection bias occurred in 1981 with a NEJM study showing an association between coffee consumption and pancreatic cancer.^[15] The selection bias occurred when the controls were recruited for the study. The control group had a high incidence of peptic ulcer disease, and so as not to worsen their symptoms, they drank little coffee. Thus, the association between coffee and cancer was artificially created because the control group was fundamentally different from the general population in terms of their coffee consumption. When the study was repeated with proper controls, no effect was seen...^[16]

[R]ecall bias, occurs when subjects with a disease are more likely to remember the exposure under investigation than controls. In the INTERPHONE study, which was designed to investigate the association between cell phones and brain tumors, a spot-check of mobile phone records for cases and controls showed that random recall errors were large for both groups with an overestimation among cases for more distant time periods.^[18] Such differential recall could induce an association between cell phones and brain tumors even if none actually exists...

A 1996 study sought to compare laparoscopic vs open appendectomy for appendicitis.^[29] The study worked well during the day, but at night the presence of the attending surgeon was required for the laparoscopic cases but not the open cases. Consequently, the on-call residents, who didn't like calling in their attendings, adopted a practice of holding the translucent study envelopes up to the light to see if the person was randomly assigned to open or laparoscopic surgery. When they found an envelope that allocated a patient to the open procedure (which would not require calling in the attending and would therefore save time), they opened that envelope and left the remaining laparoscopic envelopes for the following morning. Because cases operated on at night were presumably sicker than those that could wait until morning, the actions of the on-call team biased the results. Sicker cases preferentially got open surgery, making the outcomes of the open procedure look worse than they actually were.^[30] So, though randomized trials are often thought of as the solution to confounding, if randomization is not handled properly, confounding can still occur. In this case, an opaque envelope would have solved the problem...

The article (correctly) notes that these issues don't mean that medical knowledge is impossible -- but rather we must be diligent in looking for sources of potential error.

(Note: Reading the full text of the article requires free registration.)

Sibert Replies to Jauhar

Dr. Karen Sibert has penned a good reply to a recent Wall Street Journal OpEd by Dr. Sandeep Jauhar on the current problems with American health care.

Sibert's piece is entitled, "His diagnosis is right, but the treatment is all wrong". (Jauhar's original piece was, "Why Doctors Are Sick of Their Profession".)

Sibert discusses several important topics, including:

* The truth behind “quality” metrics
* The perils of patient satisfaction scores

She also observes:

Here is what I see as the downhill slide of 21st century medicine:

1.  The surge of uncritical belief in “evidence-based medicine” has led to rigid algorithms–cookbook recipes, really–for patient care. Experienced physicians know these algorithms are often a poor fit for patients with multiple medical problems, and must be ignored or subverted for the good of the patient.  At the same time, the physician may face criticism or sanctions for not following protocol.

2.  Bureaucrats and regulators seem convinced that if only we can produce enough care protocols, we can cut out physicians altogether and save money by having advanced practice nurses take care of everyone.  They encourage the devaluation of physician education and expertise. This seems to be the philosophy behind the proposed new VA rules which would eliminate physician supervision of veterans’ health care. (I’ll be curious to see if physician-free care will be considered good enough for the President and the Congress.)

And also:

Fee-for-service pay isn’t the chief culprit.  The best physicians stay busy because they have respect and referrals from their peers.  As they develop a base of satisfied patients and colleagues who recognize clinical excellence, they achieve financial success and have no wish to perform unnecessary procedures.  Price-fixing of physician services by third-party payers is the root cause of financial pressure to increase the number of services provided.

For more details on how our current problems and the right way to fix them, read the full text of, "His diagnosis is right, but the treatment is all wrong".

First Completely Functional Man-Made Organ

MedGadget: "Lab Created Thymus Gland is First Completely Functional Man-Made Organ"

More information from Professor Clare Blackburn: