24 July 2012

Obamacare: Is Death A Favorable Medical Outcome?

We occasionally hear about “Death Panels”. They were mentioned again on a TV program I was watching last week. The subject caught my attention because the Obamacare bureaucracy is especially concerned about the cost and efficiency of medical care for older Americans. Since I fall into that statistical category, I decided it might be wise to find out the truth.

And what did I discover?

Buried in the thousands of pages of rules, regulations, procedures, and taxes of the Patient Protection and Affordable Care Act (PPACA), there is a policy to use statistical analysis as a means of regulating patient care. Under this policy, the term “medical outcomes” acquires a whole new meaning. It will affect people with a severe disability, a catastrophic illness, or a crippling injury. The policy is also relevant for older Americans. Anyone over 65. Or maybe 50.

Why? Obamacare has promised more benefits than it can fund. (Note 1) Projections show the financial viability of both Medicare and Medicaid programs will continue to weaken as 77 million baby boomers reach retirement age.  Medicare is already burdened by an unfunded liability of $38 trillion. Obama’s response is to reduce Medicare expenditures by more than $500 billion.

Welcome to Obamacare. We are no longer people. Or patients. We are statistical “units”. Socialist philosophy theorizes it is absolutely moral to pay medical benefits based on a standard that discounts the value of a future period of life, based on the patient’s present or predicted quality of life. The calculation is called “Quality Adjusted Life Years” (QALYs). The objective of a QALY assessment is to determine the effectiveness of a specific medical procedure, versus other alternatives, for a defined population of units, -  say anyone over age 65 (or 50). The results are often expressed in comparison to the cost of the medical treatment, or cost per QALY.

Quality adjusted life years (QALYs) have been used to access the comparative effectiveness of health interventions for more than 30 years. They are frequently used as the basis of medical cost evaluations. Obamacare bureaucrats are particularly interested in reducing the cost of medical care given to people over 65 because they consume a disproportionate percentage of national health system costs. Rules, regulations and procedures are being dictated by organizations such as the Independent Payment Advisory Board, the Patient-Centered Outcomes Research Institute,  and the Centers for Medicare & Medicaid Services. (Note 2) If a medical treatment is not deemed to be statistically effective, it may not be covered under Obamacare. Procedures like annual mammographic breast screening and prostrate examinations, for example, have already been discouraged. It is a simple step to decide some medical treatments for older Americans are not cost effective, and should therefore be restricted.

Obamacare advocates obviously believe procedural cost reductions are justified.  There isn’t enough money in the Obamacare budget to fund unlimited medical treatment. Chronic, terminal, catastrophic and older units (people) account for up to 80 percent of America’s health care bill. Once we are too old to work, we will be deemed to have had a “complete life” and are no longer able to contribute to the good of society. Restricting health care for people over 65 is a positive form of social justice because these reductions allow the health system to spend more dollars on other patients. Besides, if you are old, you have already had your quota of “life years”.

Net Effect
Contemporary literature includes considerable argument against the use of QALYs (or an alternative measure of cost) in the determination of medical care policy. Detractors ask: is it ethical to replace the traditional doctor / patient relationship with uncompromising bureaucratic rules, regulation and procedures?  The answer appears to be yes. There is an obvious trend within the intellectual community to justify statistical analysis as a means of making critical health care decisions. In my opinion, there will also be a temptation to discount the value of life based on our present or predicted disability. This trend should make anyone over age 50 particularly nervous because making patients comfortable until they pass away is an alternative medical procedure. Perhaps that is why all Annual Wellness Visits for Medicare patients include questions about End-of-Life Planning and advance directives. (Note 3)

Under Obamacare: Death will eventually be considered a favorable medical outcome.

The End
Obamacare advocates can be expected to vehemently deny QALYs (or any other method of comparison) will ever be used to deny health care to anyone. “It’s against the law,” they will say. Should we believe them?

Somewhere in the great institutional bureaucracy called Obamacare is my health care record and a copy of my advance directive information. If I have a catastrophic event or debilitating illness, a stranger will look at my file and decide if I am entitled to extraordinary medical care.  Will I pass the QALY test?   Maybe not.  According to the rules, regulations and procedures of Obamacare, I’ve had my quota of good years.

 It should be obvious. When we voted for Barack Hussein Obama, we voted for Obamacare...

And QALYs.


Note 1.

Status of the Social Security and Medicare Programs
Social Security and Medicare Boards of Trustees

Both Medicare and Social Security cannot sustain projected long-run program costs under currently scheduled financing, and legislative modifications are necessary to avoid disruptive consequences for beneficiaries and taxpayers. ... The Trustees project that Medicare costs ... will grow substantially from approximately 3.7 percent of GDP in 2011 to 5.7 percent of GDP by 2035, and will increase gradually thereafter to about 6.7 percent of GDP by 2086. ... Projected Medicare costs over 75 years are substantially lower than they otherwise would be because of provisions in the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (the "Affordable Care Act" or ACA). Most of the ACA-related cost saving is attributable to a reduction in the annual payment updates for most Medicare services (other than physicians’ services and drugs) by total economy multifactor productivity growth, which the Trustees project will average 1.1 percent per year. The report notes that sustaining these payment reductions indefinitely will require unprecedented efficiency-enhancing innovations in health care payment and delivery systems that are by no means certain. In addition, the Trustees assume an almost 31-percent reduction in Medicare payment rates for physician services will be implemented in 2013 as required by current law, which is also highly uncertain. (Italics are mine)

Additional information can be found on http://medicarenewsgroup.com

Note 2.

Patient Protection and Affordable Care Act (PPACA)

Independent Payment Advisory Board
The Independent Payment Advisory Board, or IPAB, is a United States Government Agency created by the PPACA to reduce the cost of Medicare ...  beginning in 2015. The Board is prohibited from submitting proposals that would ration care, increase taxes, change Medicare benefits or eligibility, increase beneficiary premiums and cost-sharing requirements, or reduce low-income subsidies under Part D. prior to 2019. But additional cost sharing plans could be implemented aside from the IPAB’s recommendations, and the IPAB apparently has no regulatory constraints after 2018. The Department of Health and Human Services (HHS) must implement these proposals unless Congress adopts equally effective alternatives.

Beginning in 2015, the law requires the Board to submit advisory recommendations to the Congress and the President to slow the growth of national health expenditures. The IPAB is expected to cut physician fees, reduce private Medicare Advantage plans, Medicare’s Part D prescription-drug program, as well as spending on skilled-nursing facilities, home-based health care, dialysis, durable medical equipment, ambulance services, and services of ambulatory surgical centers. In addition, Obamacare trims payments to health care providers under Medicare’s current payment mechanisms.

The Patient Centered Outcomes Research Institute (PCORI)
PCORI was created to fund research that will provide patients, their caregivers and clinicians with the evidence-based information needed to make better-informed health care decisions. PCORI is developing research methods that support the engagement and meaningful inclusion of patients at every step of the research process. It is developing standards for research that anyone can use to address the health outcomes that matter to patients. PCORI is an independent, non-profit, non-governmental organization. PCORI is funded through the Patient-Centered Outcomes Research Trust Fund (PCORTF), which was authorized by Congress as part of the Patient Protection and Affordable Care Act of 2010 and receives income from two funding streams:  the general fund of the Treasury and a small fee assessed on Medicare, private health insurance and self-insured plans. PCORI is expected to receive an estimated $3.5 billion to fund patient-centered outcomes research through September 30, 2019.

A full one-fifth of PCORI’s $500 million annual budget automatically goes to HHS to support more government detailing work and “disseminate” government recommended treatment information to doctors. Government agents make medical treatment recommendations. Doctors who fail to comply are penalized and/or not paid for service. One might argue this was not the intention of the PPACA legislation, but this is happening.

Comparative effectiveness research (CER) or Cost-effectiveness analysis first appeared in the medical literature more than 40 years ago. Cost-effectiveness analysis is a systematic method of comparing 2 or more interventions (preventive, diagnostic, or treatment strategies) by measuring their costs and health outcomes. The consequences of each intervention are measured in the same common units related to the clinical objective of the interventions (life-years gained). Comparative Effectiveness Research (CER) aims to determine whether a drug or medical procedure’s are more cost-effective than alternative treatments or none at all.   (My italics)

PCORI has gone to great lengths to emphasize its patient orientated approach to CER. However, it is impossible to do CER statistical analysis without using QALYs, or a suitable substitute, to compare patient care outcomes. Some European nations already use QALY analysis to evaluate desirable (cost effective) medical treatment outcomes. As a matter of standardization, we should expect PCORI to use QALY analysis after the 2012 election.

Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) within the U.S. Department of Health and Human Services (HHS) implements medical service policy changes and manages day-to-day program operations. It establishes rules, procedures, and payment criteria for doctors, hospitals and clinics throughout the United States. The CMS decides what benefits are, and are not, available though Medicare and Medicaid. Their decisions become law, backed by the police power of the State. Doctors, clinics, and hospitals that do not comply can be fined, cut off from further payments, and professionally ostracized.

Note 3.

QALYs are a complex and contentious subject. There are thousands of documents and comments. The Affordable Care Act provides for an Annual Wellness Visit (AWV), including Personalized Prevention Plan Services (PPPS) for Medicare beneficiaries... Medicare does not provide coverage for routine physical exams.

a. For a sample of additional information, go to http://www.ncbi.nlm.nih.gov/pubmed and do a search on QALY.

b. Google “QALY and ageist”.

c. Google “advance directives”  Effective for dates of service on or after January 1, 2009, the IPPE includes end-of-life planning as a required service. Voluntary Advanced Care Planning refers to verbal or written information regarding an individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions and whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive.

d. See also David Ropeik, Are Some States of Living Worse Than Death? And Should Government Decide?  May 22, 2012
“what Mr. Obama is proposing: Namely, once health care is nationalized, or mostly nationalized, rationing care is inevitable, and those who have lived the longest will find their care the most restricted.”

e. An interesting discussion of rationing can be found here:
Resource Allocation in Health Care    cdn.intechweb.org/pdfs/24274.pdf

f. Why We Must Ration Health Care
 Peter Singer N. Y. Times, Published: July 15, 2009 http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?pagewanted=all

Extract for three key points.

Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. ... The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. ... The QALY is not a perfect measure of the good obtained by health care, but its defenders can support it in the same way that Winston Churchill defended democracy as a form of government: it is the worst method of allocating health care, except for all the others. ... If it isn’t possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?...

g. Neurosurgery 2012: Innovation or Rationing? Meet the “QALY”: Obamacare on the Frontlines.

Posted by Dr. David McKalip at Monday, April 23, 2012
“They can’t seem to comprehend, or perhaps don’t care, that the data will actually be used to deny these surgeries to those who “cost too much” or cost more than others. This is the basis of “comparative effectiveness research” (CER) that is built into Obamacare along with these registries. CER was actually first passed in February 2009, more than a year before the Obamacare law (PPACA), but it is still a major part of it and built into PPACA.  Once the government (and insurance companies) figure out who cost more, they will simply “not cover” the surgery for these patients. These are some of the patients who most need the help; those debilitated from pain or with more profound medical problems that get worse when they are debilitated. They will be made to suffer and doctors will avoid operating on these patients to avoid a bad “efficiency profile”. ”

h. Osage University Partners Blog
     Commentary for the university innovation community
     January 1, 2012 | by Martin Lehr
     2011 Review & 10 Contrarian Trends for 2012

“6) QALY begins to influence approval decisions: The recent health reform legislation strictly prohibits regulatory agencies from using the quality-adjusted life-year (QALY) threshold when making approval decisions.  Despite being legislatively prohibited from doing so, FDA advisory board panels are increasingly using QALY as part of their decision making process.  This is not really a surprise, per se, as panel members are key opinion leaders (KOLs) in their respective fields and are regularly exposed to the financial side of healthcare as many serve advisors to financial firms, start-ups, and pharma companies. So, the notion that these experts do not take a holistic view of balancing efficacy, safety, and the potential price of a drug during their decision making process is na├»ve.

On a related note, the new trend in the VC world is to encourage start-up companies to focus on QALY from day one.  VCs and start-ups see the writing on the wall, and are preparing for a world where drug pricing does impact approval and coverage decisions.  So, while the government explicitly blocks the use of QALY, everyone is using it.” 


Elliot MacLeod-Michael said...

My thoughts on the encroaching communist menace that is Nobamacare:


Celeste said...