Economic and ethical limits of medical care?

Covid-19 pandemic has caused large budget deficits in many health care units. This, together with the huge prices of many novel medical treatments, have lifted up questions of where the limits of medical treatments are. In Finland, media has approached this question by comparing the situation in Finland and USA. In Finland, health care is mainly public, so the increasing costs are paid by taxpayers.

In Finland, doctors evaluate the benefits of treatments through the probability that the treatment will give additional years of good life to the patient. During the Covid pandemic, >90% of deaths have been in the age class 70+ but most patients in intensive care units have been middle-aged. Very few Covid patients in the age class 80+ have been directed to intensive care. The reason is that an old and weak Covid patient has a low survival probability through a long period in a respirator. In most cases, intensive care would just prolong suffering. So, patients in the age group 80+ are treated in basic hospital care, not in intensive care units.

The media has claimed that the situation might be different if the costs were paid by insurance companies. What do you think about this?

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Interesting to hear that about Finland. There are a lot of ethical,concerns brought up about Covid. I think that in the US, there is a tendency to individualize treatment and to divorce costs from treatment guidelines. Whether that is good or bad is a tough question. In some countries, I understand such treatment as dialysis is cut off at a certain age, whereas in the US, it is provided until the patient elects to withdraw treatment, regardless of age.
With Covid, there are serious discussions regarding ICU treatment and DNR status, made all the more difficult by isolation. Certainly, patients with severe co-morbid conditions are encouraged along the path of terminal care, but usually if the patient wishes to have aggressive care, that care is provided. Ethics committees etc sometimes have to get involved when irrational decisions are made, but usually that is avoided. The legal system here also has molded a lot of those decisions.
Personally, I feel we in the US spend too much on end of life care, weighing quantity to the detriment of quality time, but it is a tough subject.

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I really appreciated the book Being Mortal by Atul Gawande, which talks about end-of-life care and facing death. I don’t know if it would have been approached differently if it were discussing a pandemic, but appreciated the perspective anyway, since most of this stuff is above my paygrade.

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If the patient is over 65 then they could easily have access through Medicare which is supported by tax payer money. If there wasn’t Medicare or a social safety net, then seniors would be priced out of insurance and wouldn’t have any. This would lead to less access to healthcare for seniors. For people under 65, healthcare would be doled out by economic class since those with more money can afford higher insurance premiums and better coverage.

I think American medical care is a train wreck. “The costs are paid by insurance,” means the costs are paid by the consumers. My premiums for a high deductible ($10,000) PPO for a family of five are over 1,000 USD a month. I am required to carry this insurance by my employer even though I live most of the year out of the States. When my daughter needed two stitches when we were visiting the US a couple years ago, we paid over $1200 after insurance coverage to be seen by a PA at an urgent care clinic. I paid $160 after insurance to see a PA and get a prescription for impetigo cream for my kids’s rash. It is beyond ridiculous.

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It is crazy indeed. People always thinks that just because I support capitalism it somehow means I don’t support a well regulated system that helps keep greed and consumerism in check. What’s ironic is that even with insurance, I can go to the doctors and say I don’t have insurance and pay a bill that is somehow less than if I paid with insurance. Makes no sense.

Right after spinal fusion I went through pain management and with insurance, they charged me like $1500 or something a visit and I paid $200. If I said I had no insurance, and paid for the thing out of pocket it cost me $75. I have no clue why. I asked about it. Could be the doctors goodwill… but I don’t think so since he got arrested and loss his license for giving to many drugs. Like he gave patients 3 times the amount of drugs necessary and would look past people peeing with the wrong stuff in their system or if the prescriptions they got were not even showing up meaning they were not taking them and most likely selling them.

Often very expensive, extreme measures are taken to prolong the lives of the very old, even though the time added is short and often painful.

There is certainly a need to do some rationing and some rational evaluation.

Many people react strongly against the idea of a value to additional years of life, but good planning requires some such difficult choices.

Another example is in highway design. In that case, a value of life is weighed against the probability that a life will be lost to a car accident when considering road design.

If only 1 ICU bed were available and there was the old me in need and a youngster in need, I would hope the youngster would get the help.

Nothing strange in that. Strong players like states may negotiate lower prices. The prices paid are secret but may be radically lower than the public list prices. In addition, public health care does not need to add profit on top of the prices.

These are the reasons why public health care may be much cheaper than the list price paid by individuals or private companies.

Reading the examples makes me happy that I belong to the Finnish public health care system. I guess many in USA considers the North European systems to be socialism but I don’t care. All political parties in Finland, even the right wing, supports the current health care system because the benefits are so obvious. The left wing wants that the system is kept totally within publicly funded health care units. The right wing wants that the private sector is included but so that the patients pay the same price as in the public health care units. Both wings support the possibility of choosing private health care if you pay all the costs.

I give an example of the benefits. My family has experienced two major operations during the last years. In the worse case, there were only two specialists in this part of the country who were experienced enough to do the demanding operation (risk of dying during the operation was high). Both were needed for the surgery; they operated together for 13 hours. After that, intensive care for about two days and then hospital care for about two weeks. After that, regular controls etc. You can imagine what the real price of this would be in private health care.

For my family, the current price for this is 49 euros per day in hospital. No extra fees for intensive care. The fee for a visit to a specialist doctor is 41 euros. The upper limit for yearly fees within public health care is 683 euros. Anything above that (within public health care) is free of charge.

Seems to be quite different than the price paid by most people in the USA.

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Everyone who is getting up there in age should have a living will and should leave clear instructions about end of life care.

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One journalist tried to calculate an upper limit for acceptable medical costs per person in public health care, based on EU-level guidelines. His interpretation was that, depending on how you calculate, the upper limit is 40 000 - 120 000 euros per year.

120 000 euros per year may sound much but the price of some novel medications is >200 000 euros per year. In these cases, it’s a choice between giving an individual a normal life vs. improving the health of many. Basic cost-benefit analysis but may lead to difficult decisions. Especially if it’s a choice between the life of your child vs. the health of many.

40 000 - 120 000 euros per year. Is that the value of a healthy year in life?

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It has been a few years, but I remember one conference where they said in public health they arbitrarily looked at 50,000 dollars per year of added life expectancy as a guideline as to whether a particular measure was warranted, so that is is the ballpark. That figure was used I believe in the discussion of using statins for heart disease prevention, vaccine recommendations etc. In the US, politics and interest groups distort it somewhat, as do emotional appeals. When you have limited resources, there has to be some limit.

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Even in the US, there are boards and committees that determine who gets potentially life saving treatment. This is done in the case of organ transplants. For example, an alcoholic may actually be denied a new liver or pushed down the list unless they can demonstrate they have quit drinking alcohol. People who can benefit in the long term from a new organ are prioritized above those who have poor prognoses.

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Our ‘rights’ and ‘entitlements’ culture is both a blessing and a curse. When the weak or vulnerable or elderly are denied basic rights, we scream about it (or we should anyway).

But there is a dark flip side to that. For generations now, we’ve now been marketed to think that these entitlements are themselves invulnerable. Result: we are now a population whose basic attitude toward health care and life generally is … “I want to do whatever I want, eat whatever trashy preprocessed stuff I want, indulge in whatever crazy habits I want, sit on my butt for as much of the day as I want … and I want my health care system to keep me alive and healthy 75+ years (or at least just alive for my very expensive last years) - with the expectation that I should be able to sue the system silly and at least get rich if in any way it fails me in these regards.”

There is no political party, no government, no insurance company, no nothing that can or will ever solve this health care problem for us. It is what our entitlement attitudes toward life inexorably lead to, and will remain so (among the U.S. affluent anyway) until a thoroughly sobered new generation is forced the hard way to realize life just doesn’t work that way. In our thirst for ‘paradise’, we ended up getting marketed a pile of crap by a lot of very accommodating and opportunistic corporations […and yes, even by capitalism-driven science too.]

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Are you saying that we should have some sort of government board that looks at the living habits of people on Medicare and Medicaid, and then essentially denies them access to medical treatments if they deem them not worthy?

It would seem that universal health care is the lesser of the two evils. I think it would be better if people had access to health care despite the choices they have made, compared to having a board of government officials judging whether people live or die.

Nearly every other first world country has solved it. Why can’t the US?

Of course, that is what happens in universal health care, just that those death decrees are systemically imposed so that all over a certain age have a death sentence depending on set criteria. Both systems have problems and make arbitrary decisions.

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Where does this happen in universal health care? Does this happen with Medicare?

It happens is all systems to some extent, sometimes in subtle forms, with decisions made using soft criteria where certain treatments are not approved or waiting lists exist and treatments are delayed and ultimately people die while waiting. Cost controls are present in every system, and are necessary. Those controls ultimately result in rationing care in one way or another.
Here is an article on cardiac procedure wait times in Canada:
https://www.hqontario.ca/System-Performance/Measuring-System-Performance/Measuring-Wait-Times-for-Cardiac-Surgeries-and-Procedures

Can you imagine if a patient here was told he needed bypass surgery, and the wait time to surgery was a few months? If he died in that time, you can bet there would be a lawsuit, which is another problem in our system.

Here is another article from Britain on ageism in medicine: http://news.bbc.co.uk/2/hi/health/750494.stm

Certainly, our system is broke and rations care based on ability to pay, and by doing other things like pre-authorizations of medication and procedures by insurance companies and Medicare. (If you opt for a Medicare Advantage plan, you essentially trade Medicare for a Insurance company run limited program, which controls costs by again rationing care and limiting choice.). Personally, I think Medicare is great compared to insurance companies, but if expanded to the general population would be quite costly, and would probably have to limit benefits considerably.

Some countries with more homogenous populations from an economic position have better systems than Canada and Britain, from what I see, but they too are challenged especially in the face of large immigrant influx.

I really don’t have a good answer, but think the reality of it is that there is always going to be rationing of care one way or another, as we really cannot afford to pay for unlimited care for everyone no matter the system.

The priority is obviously based on diagnosis. Not every patient needs a bypass immediately. We could also create a system in the US where there aren’t wait times. There is nothing about universal health care that requires wait times.

As to being sued, if the doctor followed the standard of care then there shouldn’t be a problem. What I think we do need in the US is a medical review board that can make judgments on malpractice suits. Having a jury rule on malpractice cases makes no sense, and a lot of lawyer fees can be saved by using a review board.

I’ve never understood the argument that expanding Medicare would be too expensive. Do people think healthcare is free for people without Medicare? The US pays twice what other first world countries are paying. We can’t afford the system we have right now.

It makes a lot more sense to base access to healthcare on health and pay for healthcare based on income. Using income as the basis for access is morally bankrupt, IMHO. We have the ability to have universal access to healthcare, we just need the want-to.

Ideally that is true. In our system however, you can always find an "expert " who will dispute whether the standard is breached or if emotions rule. I agree fully with you about the review board. In the current system, those with legitimate but less lucrative cases get ignored as they are not worthwhile for a contingency lawyer to take. That is not only true for medical, but accident cases also. No fault auto insurance has shown a much greater payout to consumers than the alternative systems in case of accident.

No real argument here on the ethical issues. I am just reminded that there is no perfect system and all make compromises, you just have to,pick your poison.

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