Friday, December 31, 2010

The Epistemology of Death Panels

Cross-posted from The Agenda on National Review Online.

Aaron Carroll of The Incidental Economist was not fond of my recent piece on state-sponsored end-of-life counseling. (As an aside, if you haven’t already, read Rich Lowry’s piece on the subject, which is basically perfect.) In my original post, I described the difference between the Left and Right on healthcare this way:

The Left’s solution is rationing: the government should determine when individuals are seeking care they don’t need, and prevent them from obtaining it. The Right’s solution is privatization: let individuals pay for the care they want, even if that means that some people are able to afford more care than others.
To which Aaron replied:
I’m sorry, but this simply isn’t true. I think [Avik is] accurately representing the position of many on the Right. But not the Left. I would say that the position of many on the Left (and it’s the “Lefty-Left”) is that government should determine what care individuals need and pay for that. For everything else, let individuals pay for the care they want, even if that means that some people are able to afford more care than others.

Notice the difference? Avik implies that the Left wants to tell you that you can’t have care you’re willing to pay for. That’s simply not true. Avik implies that the Left wants to let the government tell you that you can’t have things even when you want to pay for it out of pocket.  I have met no one – at least no one serious – that wants this.
Actually, both sides claim the same things as virtues. As per Aaron’s formulation, the Left seeks a base level of health care that is guaranteed for everyone. Anything above that, the government doesn’t pay for. Sounds reasonable enough.

However, the Right, too, seeks a base level of health care that is guaranteed for everyone, upon which the rest is left up to the individual.

So, if the Left and Right want the same thing—a base level of health care for everyone, upon which individuals can seek optional supplemental care—why are we fighting so much about health policy?

It’s because there is a gulf as wide as the Atlantic Ocean between what liberals and conservatives see as the “base level of health care” that should be guaranteed for everyone.

For conservatives, it’s catastrophic care. Outside of hard-core libertarian circles, conservatives agree that, if a woman crossing the street gets hit by a car, we should try to take care of her, regardless of her ability to afford health insurance. Outside of catastrophic care, however, health care would be far more efficient if individuals purchased consumer-driven health insurance for themselves from private insurers. (See my piece in National Affairs for a long-winded exposition of this subject.)

For the hard-core Left, there is no “base level of care.” All care should be covered, for everyone. Health policy wonks in the progressive mainstream typically take a more pragmatic view, acknowledging that we can’t afford to cover everything, so we should instead cover just about everything, except for those things that aren’t “cost effective.”

In the conservative vision, individuals decide what care isn’t cost effective: by choosing not to purchase it. In the progressive vision, the government decides, because individuals are neither competent nor wise enough to make these decisions for themselves. (Economist Ken Arrow came up with a more refined term for this view: “asymmetrical information.”)

What does this have to do with death panels? Precisely everything.

The entire reason death panels exist in Britain is because, when the NHS was founded in 1948, few people understood that making health care “free at the point of care” would lead people to use more of it: much more. To the point that today, in Britain, the U.S., and nearly every other country, health care is sinking the budget.

No country with a socialized system, including ours, has found the political will to attenuate the universal, unlimited health care entitlement, once installed. So governments come up with politically non-transparent ways to deal with the problem. One routine tactic is to pay doctors and hospitals and companies less for their services and products, leading to poorer and poorer quality.

There comes a point, however, when you’ve cut all you can cut out of hospitals’ and doctors’ pay. At a certain point, the brightest people stop applying to medical school, because they can make more money by going to law school or business school instead. At a certain point, the cost of care becomes greater than what the government pays you for that care, leading providers to do the rational thing and stop providing care. This is why we keep tweaking the notorious “Doc Fix”: because we’re already dramatically underpaying doctors for taking Medicare and Medicaid patients, relative to what they can make treating privately-insured patients.

At that point—the point at which you’ve used up all the politically easy ways to cut health-care costs—you have to start reducing the actual benefits that government-sponsored health care beneficiaries receive.

Indeed, as Bill Gardner points out, this is already happening at the U.S. state level. Arizona has begun denying Medicaid reimbursement for organ transplants. I’m not sure why, but Bill seems to see this is a rebuttal to the argument that government-sponsored health care inevitably leads to death panels. Quite the opposite.

All you have to do is see the hyperbole surrounding Paul Ryan’s exceedingly modest plan for Medicare reform to know that reducing Medicare benefits is politically difficult. So, what is the PPACA-led alternative? The Independent Payment Advisory Board, or IPAB. Peter Orzsag, Donald Berwick and other IPAB advocates hope that the new body will ultimately become an effective tool for doing exactly what the NHS does: denying state reimbursement for treatments that a group of unelected experts believe to be less useful.

I get that progressives recoil at the term “death panels.” But whatever you call them, there is simply no substantive difference in what the British NHS does today, with its National Institute for Health and Clinical Excellence (NICE), and what the founders of IPAB aim to do. Aaron himself agrees:
I think some on the Left want to use public money to pay for care, but think we can have a panel of experts (which should include physicians) try and determine which care isn’t worth the money and stop spending as much public money on that. This will mean that if individuals want to get that care anyway, they have to pay for it themselves…to some out there [this] is evidently a “death panel.”
Indeed, this is the heart of the controversy: should an unelected group of experts decide whether it’s worth spending money on the care of an individual? To progressives, the answer seems to be “Yes, obviously; individuals aren’t sophisticated enough to make these decisions for themselves.” To conservatives, the answer is “No, obviously; even if I didn’t go to medical school, I have the right to make these decisions for myself and my family.”

What I’d like to flesh out is the philosophical consistency. To the progressives who claim that IPAB isn’t meant to be a death panel: are you opposed to what NHS’ NICE does; i.e., approving reimbursement for procedures and products based upon their utilitarian impact on quality-adjusted life years? If so, why? And what method of measuring cost-effectiveness would you put in its place?


  1. Avik
    There are many shades of gray, both right and left (not just "hard core" left).

    Review this recent Dec '10 brief from AEI, which I thought was rather thoughtful and with good ideas (although I find some of it disagreeable--in a fair way). In their iteration, ie, an open bidding system, those falling under the safety net get propped up with tax credits, and in addition, the plans bid on pre-ordained set of benefits. Those benefits are not spelled out, but my read was they should embrace some basics beyond just catastrophic care--and i dont think i am too far off the mark. It does not jibe with your philosophy above.

    Additionally, I have to agree with Aaron on one point. I dont know you, but i have heard your podcasts and you sound like a bright, articulate fella who is engageable and open to discussion. What bothers me, especially being a physician, is you sound extraordinarily far removed as it relates to EOL care and advance planning.

    I have many friends in deeply conservative states who truly dislike the ACA and Obama. However, not a one is against advance planning, discussing end of life, and doing all the things say, Zeke Emmanuel advocates and Palin rails against. There beef is how it gets paid for and the health system that supports it.

    I know this is harsh, but if I was not familiar with what I know is your solid intellect, I would think your last post was hailing from the uninformed fringe. Maybe my practice with ailing, lower SES patients changes perspective; however, i cant apologize for that and I call it like i see it.

    Anyway, Happy New Year.

  2. Hi Brad,

    Thanks for your comments, both favorable and unfavorable. I don't mind criticism -- if you're going to publicly opine about something controversial, it goes with the territory.

    I've said this many times, and I did so in the other piece, but I am fully in favor of EOL counseling. As I said in the other post:

    "Yet there is no disagreement about the value of end-of-life planning. Where there is disagreement is as to the propriety of state involvement in the plan."

    We can disagree about that -- I think for you guys, the objection to state involvement seems like a triviality compared to the obvious merit and need for EOL planning -- but I've attempted to articulate on several occasions why it isn't trivial.

    Happy New Year to you as well!

  3. Avik
    Death and dying is hard. Deciding when is enough, telling a family dad is at the end (reliably), and avoiding a cost is no object exchange is virtually impossible.

    If you have not seen it, watch below. Well worth your time:

    Gives a nice snapshot of how you as a doc could imagine and react re: helping these families through their crisis. What flip cards, inventory sheets, transparency or self-enlightening device would you give a surrogate to make them more aware or informed. You cant.

    Then again, that is not the crux of the issue.

    I say this from the heart. If you asked me if the US or overseas has a more humane, decent, and successful approach to the dying process, anecdotes aside, I say from the heart overseas. That is a framework I want to be under in my time, yes, even if it means "looking at costs," But you know it all will come down to that, witness AZ, etc., and as they say, "a rose by any other name."

    If I had the choice of two panels overseeing how we would approach a remake of our system in America, say, Berwick, D Meier, Art Caplan, and E. Emmanuel vs Tom Coburn, Scott Gottlieb, David Gratzer, and John Mackey, I take the former. If you call it govt run, a mandate or death panel, I can live with that. I suppose it is just a matter of what you feel more comfortable with.

    Anyway, I would have sent you offline as this is not meant to turn into any public x-change, again this is friendly, but I really am passionate about this subject.

    Again, thanks

  4. Unspoken in your assumption, Avik, is that physicians will change the way they practice because Medicare will pay for the consultation. I dont find this argument particularly convincing. It also ignores the alternative, which is no EOL planning. I have seen no alternative plans.

    On Ryan's plan, two points. The GOP ran away from it and specifically opposed cuts in Medicare. I dont know how they will resolve that if they adopt Ryan's plan. Secondly, the plan, basically, just calls for limiting voucher spending, a form of price control. This is rationing by price. This will also be demagogued as death panels. How successful will Congress be in not raising voucher limits having seen how they folded on this claim?

    Lastly, I am with Brad here. This is a topic about which I feel very strongly as a practicing doc. This is an abstract topic for those who do not have to see these patients and their families. For those of us who do, it is a much more concrete, real problem. A very small expenditure will likely decrease suffering, result in better care and, in all likelihood, decrease spending. Standing on principle that results in a much worse outcome should, IMHO, result in scrutinization of that principle.



  5. The AEI recognizes real death panels.


  6. Hi guys,

    The main problem with your argument is that you present false choices.

    False choice No. 1: "If the state has to withhold care, best do it with a panel of experts than with a panel of politicians (or some other non-expert group)." But if we had a free-market health care system, in which individuals controlled their health care dollars, no panels, whether expert or not, would be necssary.

    False choice No. 2: "If Medicare doesn't create a specific reimbursement code for EOL counseling, EOL counseling won't happen." This is sheer conjecture. Why can't we do what La Crosse, Wisc. does and have people fill out EOL forms at every hospital admission? Many private insurers reimburse for EOL conversations. Why can't we simply include that in Medigap coverage? There are plenty of approaches to EOL counseling that don't involve the state.

    Steve, as to your comment about AEI: Ornstein is left-of-center, so while his views are worth considering on their own merits, you can't extrapolate them to the rest of AEI.

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  9. Indeed, this is the heart of the controversy: should an unelected group of experts decide whether it’s worth spending money on the care of an individual? To progressives, the answer seems to be “Yes, obviously; individuals aren’t sophisticated enough to make these decisions for themselves.” To conservatives, the answer is “No, obviously; even if I didn’t go to medical school, I have the right to make these decisions for myself and my family.”

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