Free Markets, Free People

Medicare Rationing – The Shape Of Health Care To Come

I love the way the Wall Street Journal starts this editorial about health care reform and rationing. It is something I’ve been wondering for some time here at QandO:

Try to follow this logic: Last week the Medicare trustees reported that the program has an “unfunded liability” of nearly $38 trillion — which is the amount of benefits promised but not covered by taxes over the next 75 years. So Democrats have decided that the way to close this gap is to create a new “universal” health insurance entitlement for the middle class.

In fact what they’re proposing defies logic. It is counter-intuitive (some wag said that “counter-intuitive” is the new “stupid”). I mean think about it – they’re essentially saying “we’ve run the 46% of the health care segment we have into $38 trillion of unfunded debt. The way to fix that is to give us the rest”.

But the bulk of the editorial is about who, under this new grand scheme the Democrats are proposing, will be making decision about how to treat you. And in this case one example serves to make the point:

At issue are “virtual colonoscopies,” or CT scans of the abdomen. Colon cancer is the second leading cause of U.S. cancer death but one of the most preventable. Found early, the cure rate is 93%, but only 8% at later stages. Virtual colonoscopies are likely to boost screenings because they are quicker, more comfortable and significantly cheaper than the standard “optical” procedure, which involves anesthesia and threading an endoscope through the lower intestine.

Virtual colonoscopies are endorsed by the American Cancer Society and covered by a growing number of private insurers including Cigna and UnitedHealthcare. The problem for Medicare is that if cancerous lesions are found using a scan, then patients must follow up with a traditional colonoscopy anyway. Costs would be lower if everyone simply took the invasive route, where doctors can remove polyps on the spot. As Medicare noted in its ruling, “If there is a relatively high referral rate [for traditional colonoscopy], the utility of an intermediate test such as CT colonography is limited.” In other words, duplication would be too pricey.

Consequently, because there might be a percentage of referrals (that Medicare assumes might be “relatively high”) which then require a traditional colonoscopy, no Medicare patients may have the virtual colonscopies even if they are quicker, more comfortable and, as with any invasive procedure, less dangerous.

Now I assume I don’t have to lay out all the implications of this to readers here – this is prefect example of precisely what opponents of government health care have been saying for years. And it certainly gives lie to the claims by some that all government wants to do is offer “insurance”.

Led by budget chief Peter Orszag, the White House believes that comparative effectiveness research, which examines clinical evidence to determine what “works best,” will let them cut wasteful or ineffective treatments and thus contain health spending.

The problem is that what “works best” isn’t the same for everyone. While not painless or risk free, virtual colonoscopy might be better for some patients — especially among seniors who are infirm or because the presence of other diseases puts them at risk for complications. Ideally doctors would decide with their patients. But Medicare instead made the hard-and-fast choice that it was cheaper to cut it off for all beneficiaries. If some patients are worse off, well, too bad.

One of the complaints about private health insurers is that patients resent someone group on high deciding what is best for them. That should be their doctor’s decision. Yet here is that complaint being sanctioned for the largest purchaser of health care in America – Medicare. And, as the WSJ points out, since private carriers usually adopt Medicare rates and policies, the virtual colonoscopy could be a technology which is “run out of the market place”.

Mr. Orszag says that a federal health board will make these Solomonic decisions, which is only true until the lobbies get to Congress and the White House. With virtual colonoscopy, radiologists and gastroenterologists are feuding over which group should get paid for colon cancer screening. Companies like General Electric and Seimens that make CT technology are pressuring Medicare administrators too. More than 50 Congressmen are demanding that the decision be overturned.

All this is merely a preview of the life-and-death decisions that will be determined by politics once government finances substantially more health care than the 46% it already does. Anyone who buys Democratic claims about “choice” and “affordability” will be in for a very rude awakening.

Is this how you want health care decisions affecting your life to be made? Political fights in Congress? Look at the financial health of the US government right now and consider the huge unfunded liabilities in front of it. What side do you really think such decisions will come down on – yours or the least costly alternative regardless of your individual need?


[HT: Anna B]

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5 Responses to Medicare Rationing – The Shape Of Health Care To Come

  • This administration already feels like one long colonoscopy.

  • “If there is a relatively high referral rate [for traditional colonoscopy], the utility of an intermediate test such as CT colonography
    is limited.”

    Why would there be a high referral rate in the first place?  It’s a routine, recommended procedure once you reach a certain age.

  • I can answer the question from above – I manage an Endoscopy unit which performs colonoscopy procedures.  Our hospital also offers CT colonography (Virtual colonoscopy).  We experience what has been referenced above on a weekly basis.  It is extremely difficult to tell on a CT if a “flat lesion” or other lumpy-type substance is stool or if it’s potentially a cancerous lesion.  The only way to confirm this is to send the patient for a “conventional” colonoscopy, which is now largely performed under IVGA (iv general anesthesia) and with the patients completely losing consciousness.  This is a change from the old “bend over and bite this bit” method of 15 years ago.  Ergo, CT colonography is only a good exam if your patient has absolutely A) no family history of cancer or polyps; B) no personal history of same; C) no history of diverticular disease (an “inverted” diverticulum is another thing that can mask itself as a polyp in the colon, hard to differentiate on a CT whereas in a conventional Colonoscopy it can be poked/prodded); D) a perfect colon preparation with ZERO stool still present.  If that “perfect storm” can be achieved, then the test may well save that type of person from needing to come to my lab and get the conventional exam.  Otherwise, we’ll be seeing them.  Medicare has an obligation to fund testing and procedures that have a high yield and low return rate for add’l procedures.  In a way, it is ironic that some of these very tests (and this is no knock on them as they are my bread and butter) contribute to the overloading of this system that was originally intended only to care for folks a few years beyond retirement.  People are living longer each year due to the efficacy of these testing modalities.

  • Grimshaw, the progression is that a positive of any type of a virtual colonoscopy almost always requires a real colonoscopy, except when even more invasive measures are required.  The virtual colonoscopy are entirely diagnostic in nature and includes nearly no surgical capabilities, so any unusual things detected must be dealt with through other means; since the other means are either a real colonoscopy to remove smaller polyps or surgery for larger masses.

    Virtual colonoscopy could replace real colonoscopies as an initial measure — that is, real colonoscopies would no longer be a recommended procedure when a less painful and dangerous method were available.  There are  a number of reasons for this, primarily that the conventional colonoscopy is simply not fun for anyone involved.   It involves essential sticking several meters of hose up where the sun does not shine, and the prep is worse.  The latter part is present for virtual colonoscopy, but not the former.  It’s actively dangerous, as with any other procedure involving anesthesia or invasive procedures, and while rare, people have died from complications of the testing procedure.  Simply making it sound less bad will save lives, as fewer people resist doctor advice to have the procedure done.

    On the other hand, the CT colonography involves non-trivial costs and small but existent risks of its own.  That’s common in medical tech.

    But we have a lot of people who are good at making decisions about this.  That they’re only going to be tangentially involved is the problem.

  • Vera,

    Thanks for the explanation.