Monday, August 24, 2009

Nationalized healthcare

People in the United Kingdom during my two years residency there spent much time complaining about their National Health System (NHS). However, if anyone else criticized the NHS, the Brits almost invariably rushed to defend NHS as superior to other systems. In particular, they pointed to several advantages of NHS over the U.S. approach: people can change jobs without worrying whether their healthcare coverage is portable; pre-existing conditions are no barrier to care; everybody has coverage; NHS costs less than U.S. healthcare and delivers better outcomes.

Incredibly, one third of Medicare spending goes to patients with less than two years to live. People desperate to live want to exhaust every possible cure or treatment options that, falling short of a cure, will at least extend life.

Too often, people in end of life situations receive the wrong care. First, hospice care is not uniformly available, allowing some people (sometimes aided, other times emotionally coerced by their family) to avoid facing the reality of death. Spiritually and emotionally, affording people time to make peace with self and others is a precious element of life that hospice often facilitates.

Second, modern medicine still cannot cure every disease nor can medicine alleviate every symptom. Patients frequently want to ignore those truths, relentlessly pursuing an imaginary “fountain of youth” that will restore them to health. Humans, like all life forms, exemplify planned obsolescence, i.e., birth necessarily and inevitably leads to death. People should not actively seek death but should also not believe that death is escapable. Similarly, healthcare providers should honestly and consistently inform patients when no treatment has proven beneficial rather than caving into patient expectations and the false notion that a patient’s death represents a healthcare system failure. That’s simply bad science and bad theology.

Morally, the single-minded pursuit of any possible treatment or cure diverts scarce resources from people who could greatly benefit from additional care. The U.S. wrongly rations healthcare based on a person’s ability to pay for the care. In the case of Medicare, reducing money wasted on ineffectual care expends funds that could provide healthcare for those without coverage.

Thus, patients and families have an ethical obligation to weigh the cost of healthcare against potential benefits (extending life, improving the quality of life). The U.S. approach to healthcare does not give medical providers or recipients a motive to address that question. Providers are paid on a fee per service basis, i.e., each service provided generates income. Few recipients pay for their own care and determining the cost of a procedure in advance is almost impossible, having attempted to do so on several occasions. (Tangentially, without full cost data no free market can function effectively or efficiently.)

Third, the practice of modern medicine should incorporate a more scientific, less anecdotal approach. That is, providers should determine the appropriate treatment by assessing the probability of success based on a national database of past usages. Given the pertinent factors A, B, and C for a person of N years and G gender (plus any other relevant information), has treatment option X or Y produced the best results? No such complete database now exists. Furthermore, providers often prescribe treatments according to personal preference, personal knowledge, or vendor provided information. Most expensive is not always best.

Fourth, fear of malpractice suits should not drive delivery of healthcare. Currently, U.S. healthcare providers generally practice defensive medicine, ordering tests and treatments to minimize the potential of malpractice suits. Tests both waste scarce resources and occasionally cause further complications. Why, for example, should a doctor order a test to learn more about a condition for which no known efficacious treatment exists? Why should a doctor order a test to learn more about a condition for which the patient does not intend to undergo treatment?

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